Get Employee Physical Form

Get Employee Physical Form

The Employee Physical Examination Form is a crucial document used by employers to assess the health and fitness of potential hires. This form gathers essential medical history and physical examination details to ensure that employees can safely perform their job duties. To get started, please fill out the form by clicking the button below.

Structure

The Employee Physical Examination Form serves as a crucial tool for employers to assess the health and fitness of potential employees. This form collects essential personal information, including the employee's name, job title, date of birth, and physical measurements such as height and weight. A significant section of the form is dedicated to the medical history, where employees must disclose any past or present health conditions, ranging from arthritis and asthma to heart disease and tuberculosis. Each condition requires a simple 'yes' or 'no' response, and if any 'yes' answers are given, the employee must provide further details. Additionally, the form includes a comprehensive physical examination checklist, covering various aspects of health such as general appearance, skin condition, and musculoskeletal functioning. The examining physician will review the medical history and perform a physical examination, ultimately determining the applicant's fitness for employment. This thorough process helps ensure a safe and healthy work environment for all employees.

Employee Physical Preview

P 908 312 1423 - www.fivestar.care - F 908 325 1975 216 River Avenue Suite 207 Lakewood, NJ 08701

EMPLOYEE PHYSICAL EXAMINATION FORM

PAGE 1

Last Name:

First Name:

Middle Initial: Today’s Date:

MEDICAL HISTORY: Do you now have, or have you ever had, any of the following:

 

 

 

YES

NO

 

 

YES

NO

 

 

1.

Arthritis / Rheumatism

 

 

10.

Hepatitis A; B; C; other Infections

 

 

 

 

2.

Asthma / Wheezing

 

 

11.

Hernia(s)

 

 

 

 

3.

Back Injury/ Chronic Back Pain

 

 

12.

Hypertension /High Blood Pressure

 

 

 

 

4.

Broken Bones / Fractures

 

 

13. Jaundice / Liver Disease

 

 

 

 

5.

Cancer

 

 

14.

Sinus Trouble / Allergies

 

 

 

 

6.

Diabetes

 

 

15.

Skin Disease

 

 

 

 

7.

Emphysema / Lung Disease

 

 

16.

Stomach Trouble / GI Problems

 

 

 

 

8.

Head Injury / Unconsciousness

 

 

17.

Substance Abuse (History of Drug

 

 

 

 

 

 

 

 

 

or Alcohol Abuse Problems)

 

 

 

 

9.

Heart Disease / Heart Attack

 

 

18.

Tuberculosis or History of Positive

 

 

 

 

 

 

 

 

 

TB Skin Test

 

 

 

I have read the above and declare that I have no injury, illness or ailment other than is specifically noted above. Any falsification or misrepresentation will be sufficient grounds for my release from employment.

Employee’s Signature

Date

Any “YES” answer(s), please explain below.

Put the number (1, 2, 3, etc.) of the YES answer before the explanation:

( Example: “#12. I have been taking medication for high blood pressure since 2007.”)

P 908 312 1423 - www.fivestar.care - F 908 325 1975 216 River Avenue Suite 207 Lakewood, NJ 08701

EMPLOYEE PHYSICAL EXAMINATION FORM

PAGE 2

Last Name:

 

 

 

 

 

 

 

First Name:

 

 

 

 

Middle Initial:

 

Today’s Date:

 

Job Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOB

 

Age

 

Sex

 

HT

 

WT

 

Temp.

Pulse

Resp.

 

B/P

 

Drug/Food Allergies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision: R 20/

 

 

L 20/

 

Pupils: Equal

 

Unequal Glasses/Lenses: Y / N

Hearing: Normal Impaired Hearing Aid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL EXAM

 

 

 

NORMAL

 

ABNORMAL

 

 

 

COMMENTS

1.

General Appearance / BMI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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5.

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Lungs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Heart

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Abdomen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

GU System

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Musculoskeletal Functioning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Full ROM to all extremities? History

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of injury to knees or hips?)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Back / Spine (History of injury?)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Neurological (Gross observation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of gait, coordination, tremors, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Psychiatric (tics, stuttering, nail-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

biting, cognition, orientation, affect,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

obvious personality disorders, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s review of person’s medical history as recorded on reverse side of this form:

PPD / Mantoux Test for Tuberculosis: 1st Step Date:

 

 

 

_ Result:

_ 2nd Step Date:

Result:

 

Chest X-Ray: Date Performed:

 

 

Results:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS APPLICANT IS FIT FOR EMPLOYMENT: YES:

 

 

 

 

NO:

 

 

Deferred for Functional Capacity Evaluation:

 

 

 

 

 

 

 

 

Examining Physician’s Signature

 

Date Physical Examination Performed

Document Data

Fact Name Fact Description
Purpose The Employee Physical Examination Form assesses the medical history and physical condition of employees.
Medical History The form includes a comprehensive list of health conditions for employees to report, such as asthma and heart disease.
Signature Requirement Employees must sign the form, confirming the accuracy of their medical history and acknowledging potential consequences for misrepresentation.
Physical Examination A physical examination is conducted, covering aspects like general appearance, lungs, heart, and neurological health.
Vision and Hearing The form includes sections to evaluate vision and hearing, noting any impairments or the use of aids.
State-Specific Regulations In New Jersey, the governing law includes the New Jersey Workers' Compensation Act, which mandates health assessments for certain jobs.
Fit for Employment The examining physician must indicate whether the applicant is fit for employment based on the physical examination results.
Follow-Up Tests Tests such as the PPD/Mantoux Test for tuberculosis may be required, with results documented on the form.

How to Use Employee Physical

Completing the Employee Physical form is an important step in your employment process. After you fill out this form, it will be reviewed by a medical professional to ensure you meet the health requirements for your job. Follow the steps below to complete the form accurately.

  1. Begin with your personal information at the top of the form. Fill in your Last Name, First Name, and Middle Initial.
  2. Enter Today’s Date in the designated space.
  3. In the MEDICAL HISTORY section, read each question carefully. For each condition, mark YES or NO.
  4. If you answered YES to any question, provide an explanation in the space provided below. Use the number of the question for reference.
  5. Sign and date the form to declare the information is accurate and complete.
  6. On the second page, fill in your Job Title, Date of Birth (DOB), Age, and Sex.
  7. Complete the sections for Height (HT), Weight (WT), Temperature (Temp), Pulse, Respiration (Resp), and Blood Pressure (B/P).
  8. Indicate any Drug/Food Allergies you may have.
  9. Provide your vision information in the format specified (e.g., R 20/ L 20/).
  10. Check the appropriate box for your hearing status: Normal, Impaired, or Hearing Aid.
  11. For the PHYSICAL EXAM section, indicate whether each aspect is NORMAL or ABNORMAL. Add comments if necessary.
  12. Ensure the Physician’s review section is completed by the examining physician, including the results of any tests performed.
  13. Finally, confirm whether you are fit for employment by marking YES or NO.

Key Facts about Employee Physical

What is the purpose of the Employee Physical form?

The Employee Physical form is designed to assess the medical fitness of an employee for their specific job role. It gathers essential medical history, physical examination results, and any relevant health concerns that may impact job performance. This form helps employers ensure that employees are capable of fulfilling their job responsibilities safely and effectively.

What information is required on the Employee Physical form?

The form requires personal information such as the employee's last name, first name, middle initial, job title, date of birth, age, sex, height, weight, and vital signs including temperature, pulse, respiration, and blood pressure. Additionally, it includes a detailed medical history section where employees must indicate any past or present health issues, as well as a section for physical examination results.

How should I report any health issues on the form?

What happens if I do not disclose a medical condition?

Failure to disclose a medical condition can lead to serious consequences, including potential termination of employment. The form includes a declaration stating that any falsification or misrepresentation of information may result in release from employment. It is crucial to provide accurate and complete information to ensure your safety and compliance with workplace requirements.

Who reviews the Employee Physical form?

The form is reviewed by a qualified examining physician who assesses the medical history and physical examination results. The physician will determine whether the applicant is fit for employment based on the provided information. This review ensures that any health concerns are appropriately addressed before the employee begins work.

What should I do if I have a history of substance abuse?

If you have a history of substance abuse, it is important to disclose this information on the form by checking "YES" next to the relevant question. Providing this information allows the employer to understand any potential impacts on job performance and safety. Employers may offer support and resources to help employees manage their health and maintain a safe working environment.

Can I request a copy of the completed Employee Physical form?

Yes, employees can typically request a copy of their completed Employee Physical form. It is advisable to inquire about the process for obtaining a copy when submitting the form. Keeping a personal record of your medical examination can be beneficial for future reference or if any questions arise regarding your health status in relation to your job.

Common mistakes

Filling out the Employee Physical form can seem straightforward, but there are several common mistakes that people often make. One of the most frequent errors is neglecting to provide complete personal information. While it may seem minor, omitting details like the middle initial or date of birth can lead to confusion later in the process. Ensure that all sections are filled out accurately to avoid unnecessary delays.

Another common mistake is misunderstanding the medical history section. Many individuals may skip over this part or fail to answer honestly. It's crucial to answer all questions, especially those related to past medical conditions. If there’s any uncertainty about a condition, it’s better to clarify than to leave it blank. Misrepresentation can have serious consequences, including potential termination of employment.

Some people also overlook the importance of explaining any "YES" answers in the designated area. Simply marking “YES” without providing context can raise red flags for employers. This section is an opportunity to clarify any health issues, so take the time to provide detailed explanations. For example, if you answer “YES” to having hypertension, specify the treatment or management plan you follow.

Additionally, failing to update weight and height can lead to inaccuracies in health assessments. These measurements are often used to calculate Body Mass Index (BMI), which is an important health indicator. Regularly check these details before submitting the form to ensure they reflect your current state.

Another mistake involves the physical examination section. Some individuals may not pay close attention to the “Normal” or “Abnormal” checkboxes. It’s essential to be honest about your physical condition. If you have any concerns about your health, discussing them with your physician during the examination is vital.

People sometimes forget to sign and date the form. This might seem trivial, but an unsigned form is incomplete and may delay the hiring process. Always double-check that your signature is present and that the date is accurate before submission.

Moreover, neglecting to disclose any drug or food allergies can pose significant health risks. This information is crucial for your safety and should be clearly indicated on the form. If you have allergies, list them explicitly to ensure that your employer is aware of your needs.

Finally, many individuals may not review the entire form before submitting it. Taking a few extra moments to go over each section can help catch any mistakes or omissions. A thorough review can make a significant difference in ensuring that your application is processed smoothly.

Documents used along the form

When onboarding new employees, several forms and documents complement the Employee Physical form to ensure a comprehensive understanding of the employee's health and readiness for work. Each of these documents plays a vital role in the overall evaluation process, helping employers maintain a safe and healthy workplace.

  • Health History Questionnaire: This document gathers detailed information about an employee's medical background, including past illnesses, surgeries, and family health history. It helps identify any potential health risks that may affect job performance.
  • Consent for Medical Treatment: Employees sign this form to authorize medical professionals to provide necessary treatment or care during the physical examination. It ensures that the employee is informed and agrees to any procedures that may be performed.
  • Immunization Records: This document provides a record of the employee's vaccinations, which is particularly important in healthcare and other industries where exposure to infectious diseases is a concern. It helps verify that the employee is up to date on necessary immunizations.
  • Job Description: A clear job description outlines the physical demands and responsibilities of the position. This document helps assess whether the employee is physically capable of performing the required tasks and highlights any specific health considerations related to the job.
  • Return-to-Work Authorization: After an employee has been away from work due to health reasons, this form is necessary for them to return. It confirms that the employee has been cleared by a healthcare provider to resume their duties without restrictions.

By utilizing these documents alongside the Employee Physical form, employers can create a thorough health profile for each new hire. This comprehensive approach not only protects the well-being of employees but also fosters a safer workplace environment.

Similar forms

The Employee Physical Examination Form is an essential document that serves various purposes in the employment process. Several other documents share similarities with this form, particularly in their focus on health assessments and medical history. Below are six documents that are comparable to the Employee Physical Form:

  • Health History Questionnaire: This document collects information about an individual's past and present health conditions. Like the Employee Physical Form, it includes questions about chronic illnesses and previous injuries, ensuring that employers are aware of any potential health risks.
  • Pre-Employment Medical Assessment: This assessment evaluates a candidate's physical and mental fitness for a specific job. It often includes similar medical history questions and physical examinations, similar to those found in the Employee Physical Form.
  • Return-to-Work Form: After an employee has been on leave due to medical reasons, this form assesses their readiness to return to work. It often requires a review of the individual's medical history and any ongoing health issues, paralleling the information requested in the Employee Physical Form.
  • Occupational Health Assessment: This document evaluates an employee's health in relation to their job duties. It includes a review of medical history and physical examinations, akin to the Employee Physical Form, to ensure that employees are fit for their specific roles.
  • Disability Assessment Form: Used to determine an individual's eligibility for disability benefits, this form gathers comprehensive medical history and current health status. It shares a similar structure and intent with the Employee Physical Form in assessing health-related issues.
  • Wellness Screening Questionnaire: This document aims to identify health risks and promote preventive care among employees. It includes questions about medical history and lifestyle factors, mirroring the focus of the Employee Physical Form on health and wellness.

Dos and Don'ts

When filling out the Employee Physical form, it’s essential to approach the task with care and attention. Here’s a helpful list of things to do and avoid to ensure the process goes smoothly.

  • Do read all instructions carefully before starting.
  • Do provide accurate and honest answers regarding your medical history.
  • Do double-check your personal information for any errors.
  • Do explain any "YES" answers clearly in the designated section.
  • Do sign and date the form after completing it.
  • Don't rush through the form; take your time to ensure accuracy.
  • Don't leave any sections blank unless instructed to do so.

By following these guidelines, you can help ensure that your Employee Physical form is completed correctly, which is important for your employment process.

Misconceptions

Understanding the Employee Physical form can be challenging, and misconceptions often arise. Here are some common misunderstandings:

  • It's just a formality. Many people think the Employee Physical form is a mere formality, but it plays a crucial role in ensuring that employees are fit for their specific job roles.
  • Only new employees need to fill it out. This is not true. Current employees may also be required to complete the form for various reasons, such as changes in job duties or health status.
  • It’s only about physical health. While physical health is a major focus, the form also addresses mental health and any history of substance abuse, which can impact job performance.
  • All information is confidential. Although the information is treated with care, there are circumstances under which it may be shared with relevant parties, such as supervisors or safety personnel.
  • Only serious conditions need to be reported. Employees should report any health issue, no matter how minor it may seem. Even minor conditions can affect job performance or safety.
  • My employer can’t ask about my medical history. Employers have the right to request this information to ensure workplace safety and compliance with health regulations.
  • Falsifying information is not a big deal. Misrepresentation can lead to serious consequences, including termination of employment. Honesty is essential.
  • The form is only for certain job types. In fact, all employees may be required to complete the form, regardless of their job role, especially if their work involves physical activity.

By clarifying these misconceptions, employees can better understand the importance of the Employee Physical form and approach it with the seriousness it deserves.

Key takeaways

Key Takeaways for Filling Out and Using the Employee Physical Form

  1. Ensure all personal information is accurate, including last name, first name, and today’s date.
  2. Complete the medical history section thoroughly. Indicate “YES” or “NO” for each condition listed.
  3. If you answer “YES” to any medical condition, provide a detailed explanation in the designated area.
  4. Understand that any false information may result in termination of employment.
  5. Fill out the physical examination section carefully, noting any abnormalities observed during the examination.
  6. Be aware of your vital statistics, including height, weight, temperature, pulse, and respiratory rate, as these are required.
  7. Report any drug or food allergies clearly to ensure safety in the workplace.
  8. Provide information on vision and hearing, including whether corrective lenses or hearing aids are used.
  9. Obtain the examining physician’s signature to validate that the physical examination was performed and reviewed.