Employee Physical Examination Form printable pdf download

Employee Physical Examination Form

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60 Katona Drive - Suite 18

Fairfield, CT 06824

Tel (203) 256-1804 Fax (203) 259-8523

Employee Physical Examination

Date of

Name:

SS#:

Birth

ZIP

Address:

City/ State

Code

Consent for Examination and Release of Information:

____________________________________

_________________________

Signature of Applicant/Employee

Date

Physical Therapist

Home Health Aide

Speech Therapist

Registered Nurse

Occupation Therapist

Licensed Practical Nurse

Masters in Social Work

Clerical

Type of Physical:

( please check one)

Annual

Return to Work

Pre-Employment

(due every 3 years)

Note to Physician:

The above named is/will be employed as a health care provider. We are interested in your medical

evaluation of this person’s ability to function in this capacity based upon a physical examination and

significant laboratory tests. In this regard would you please complete the following:

FOR PHYSICIAN ONLY--

Medical History

Neurological

YES NO

If YES, indicate degree of function disability

 Seizure Disorder (Epilepsy)

 Dizziness/Fainting

 Weakness/Paralysis

 Swelling of lower extremities

Infectious Disease

YES NO

If YES, indicate degree of function disability

 Tuberculosis

 Hepatitis

 Mumps

 Measles

 Syphilis

 Gonorrhea

Employee Physical Examination Form

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