Employee Physical Examination Form (Page 2 of 2) in pdf

Employee Physical Examination Form Page 2

W-2 page 2 of 2

Medical History (continued)

Drug Use/Abuse

YES

If YES, indicate type and amount

 Depressants

 Stimulants

 Narcotics

 Alcohol

Physical Examination

Date of Examination_______/_____/____

Weight

Height

Blood Pressure

Check all those that apply and explain below:

Condition

Eyes

Ears

Nose

Throat

Heart

Lungs

Back

Normal

Abnormal

Explanation:______________________________________________________________

Laboratory Test (**Required)

Date Done

Date Read

Results

 TB Skin Test (PPD) yearly

 Chest X – Ray

(mandatory for positive PPD)

 Hepatitis B Vaccine Series:

Dates given

Comments (including limitations if any):

I certify that I have conducted a physical examination on the above named person on this date and

he/she is free of any communicable disease and from habituation and addition to alcohol, narcotics,

stimulants, drugs or other substances, which may alter behavior. In my opinion, he/she can

adequately perform the functions of a health care provider.

Physician’s

Date:

Name:

Signature

Physician’s

NPI#

Address:

Telephone #:

Employee

Date:

Signature:

Reviewed By:

Date:

Employee Physical Examination Form Page 2

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