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Employee Physical Examination Employee Physical Examination – Annual Exam

Employee Physical Examination Employee Physical Examination – Annual Exam



Employee Physical Examination
To be
completed by physician . Circle or check all that
applies
Name
____________________________
Nationality _________________ D.O.B___________________
Position
applied for _______________ Date Hired _________ Department ____________ . Address_________________________________________
Home telephone __________________________.
Allergies ________ Height _______ Weight _______ Vital Signs Temp._____ Resp.___
BP;L _____/ ____ R_____/ ____ .
CHEST X- RAY
 
 
Date of last X – Ray
One every 12 months
abnormal
normal
Tuberculosis
positive
negative
I certify I have examined the named above to the medical
standards and have found him / her fit for duty .
Printed name of examining physician
_____________________ Signature _________________
Address of examining physician
___________________________________________________
Telephone __________________________ .
Exam
Date _____________
Employable : Yes ____
Employee Physical Examination – Annual Exam
To be completed by
physician
Address____________________________________ Phone
_________________________
Name ______________________ Nationality _____________
D.O.B __________________
Address ___________________________________________ Phone
_________________
All lab results are to be forwarded with this form . All abnormal results and physical findings
are comment on general appearance
and mental attitude .
Circle or check all that applies .
1.
Intact cranial
yes
no
2.
Nerves reflex 1-
12
yes
no
3.
Intact perif.
nerves
yes
no
4.
Abnormal
curvatures
5.
of the spine or back
yes
no
6.
Recurrent back pain
yes
no
7.
Cervical pain
yes
no
8.
Adenopathy
yes
no
9.
Alaxia
yes
no
10.
Arthritis: Osteon
yes
no
11.
Rheumatoid
yes
no
12.
Dependant edema
yes
no
13.
Varicose venis
yes
no
14.
Plantar warts
yes
no
15.
Muscle atrophy
yes
no
16.
Skeletal deviation
yes
no
17.
Flat feet
yes
no
18.
Hx. of
Gout
yes
no
19.
Hx. of Typhoid
fever
yes
no
I certify that I have examined
Mrs._____________________________ and I have found him in normal mental
attitude and employable.
Printed name of physician :______________________________
Signature :
Exam Date :

  • Date: Kwiecień 18, 2013
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