Comprehensive History Physical Exam Form - Middlesex Hospital Page 2
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2.
PATIENT NAME: ______________________________________________________________
DOB: _________________________
C. OCCUPATIONAL PROFILE
Back History:
Yes
No
Explain:
1)Have you ever experienced back injury that resulted in:
Lost time from work/school
Visit to the doctor
Visit to the chiropractor or physical therapy
2)Have you ever had:
Back x-rays , CT Scan or MRI
Have you ever been or are you now exposed to any of the following? Have you ever been treated for any of the following?
Exposed
Treated
Exposed
Treated
Exposed
Treated
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Metals
Extreme Heat / Cold
Loud Noise
Fumes
Chemicals
Radiation
Vibration
Biologic Agents
Blood/Bodily Fluids
Dust or Fibers
If you answered YES to any of the questions above, please provide additional details:
Dates of Employment
Job Title / Description of work / Employer
Exposures (chemicals, blood, etc…)
Have you ever received Disability or Compensation Benefits?
Yes
No If yes, indicate where and when:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Have you ever lost time at work due to an injury or illness?
Yes
No If yes, explain:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Have you ever been advised to change jobs or work assignments because of any health problems or injuries?
Yes
No If yes,
explain: _________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
List any problems that you wish to discuss with the doctor: _______________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
D: MEDICAL DECLARATION
I CERTIFY THAT THE FOREGOING IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE I UNDERSTAND THAT I MAY BE REQUESTED
AT THE OPTION OF MY EMPLOYER TO COMPLETE A PHYSICAL EXAMINATION I AUTHORIZE ANY OF THE DOCTORS, CLINICS OR
HOSPITALS MENTIONED ABOVE TO FURNISH A COMPLETE TRANSCRIPT OF MY MEDICAL RECORD FOR PURPOSE OF PROCESSING MY
APPLICATION FOR THIS EMPLOYMENT, SUBJECT TO CONFIDENTIALITY STATUTES
Date: __________________ Signature: _________________________________________________________________________________
Reviewed by: _______________________________________________________Date:_________________________Time:______________
Rev. 11/14
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