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.
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.
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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
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.”)
PAGE 2
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
General Appearance / BMI
Skin
HEENT
Teeth
Neck
Lungs
Heart
Abdomen
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
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.
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.
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.
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.
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.
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:
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.
By following these guidelines, you can help ensure that your Employee Physical form is completed correctly, which is important for your employment process.
Understanding the Employee Physical form can be challenging, and misconceptions often arise. Here are some common misunderstandings:
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 for Filling Out and Using the Employee Physical Form