EMPLOYEE PHYSICAL EXAM FORM - PDF

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					                                    EMPLOYEE PHYSICAL EXAM FORM
                                Please return completed form to the Personnel Office
                                      53 Gibson Road, Goshen, New York 10924

Employee’s Name:                                           Age:

Address:                                                   SS #

                                                           Blood Type:

Telephone:                                                 Allergies:

General Appearance:

Height:                                  Present Weight:                        Normal Weight:

Skin:

Eyes:
          General Condition:                               R                             L

          Vision (without glasses):                        R                             L

          Vision (with glasses if applicable):             R                             L

          Visual Acuity Test Used:

          Is color vision normal:
Ears:
          General (Otoscopic)                              R                             L

          Hearing (Audiometer Testing Rec.)                R                             L

Nasopharynx:                                               Nasal Obstruction:            Tonsils(diseased?):

Mouth:                          Teeth:                         Oral Hygiene:             Malocclusion:

Speech:                         Clear:                         Coherent:                 Impediment:

Glands:                         Enlarged Thyroid:                          Enlarged Lymph Nodes:

Chest: Lungs                    R                                          L
(Pathology)
Cardiovascular System:          Blood Pressure:                            Pulse Rate:

Regular, Irregular, Tachycardia:

Heart:
Abdomen:

Hernia (Actual or Potential):                                        Type(Inguinal or other):

Gastro-Intestinal:

Genito-Urinary:

Bones-Muscles:                Spine:                     Feet:                       Posture:

Nervous System:                        Reflexes:                          Tremors:

Veins (Varicose):                      Present:                           Degree:

Other:
         Disfiguring Scars:

         Evidence of growth or tumors:

         Symptoms (or history) of alcoholism or drug addiction:

         Estimate of emotional stability:

                                         Required Laboratory Tests
Urine:                                 Sugar:                             Albumin:

Tuberculin Test:                       Date Administered:                 Result:

Results of most recent Chest X- Ray(Chest X-Ray is required if there is a history of TB or exposure to TB)

Date of X-Ray:                                     Result:

Immunizations:
Polio Immunization: Year:                          Smallpox Vaccination: Year:


     I hereby certify that ___________________________________________________has been
examined by me. In my opinion the above named person is free from contagious disease and is/is not
physically fit to perform the duties of _________________________________.
                                            Job Title

     If applicant or employee is not physically fit in your judgment, but condition can be corrected,
please enter below treatment indicated.

_____________________________________________________________________________________



Date:                         Medical Examiner’s Signature: ____________________________________