Occupational Health History/exam Form Page 4
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4VIBRANT HEALTH FAMILY CLINICS
PHYSICAL EXAMINATION RECORD
Full Name: _________________________________________________ Date of Exam:_________________________
Allergies: ____________________________ Medication:_________________________________________________
Family History: Explain any significant familial diseases such as Hypertension, Heart Disease, Diabetes, Cancer etc.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
General Appearance:
Good ______ Fair ______ Poor ______ HT ______ WT ______ BP ______ P ______
Vision:
R 20/_____ L 20/_____ Both 20/_____
_____ With_____ Without corrective lenses
Color Vision:
Normal ______ Abnormal ______
Depth: Normal ______ Abnormal ______
Audiogram:
_______ Not requested
_______ Completed
Pulmonary Screen:
_______ Not requested
_______ Completed
Physical Exam
Normal
Abnormal
HEENT:
_____________
__________________________________________________
Hearing:
_____________
__________________________________________________
Thorax:
_____________
__________________________________________________
Heart:
_____________
__________________________________________________
Lungs:
_____________
__________________________________________________
Abdomen/GL
_____________
Hernia: Y ____ N ____ Location ________________________
Genito-Urinary
_____________
__________________________________________________
Neurological:
_____________
__________________________________________________
Extremities:
_____________
__________________________________________________
Upper:
_____________
__________________________________________________
Lower:
_____________
__________________________________________________
Spine:
_____________
__________________________________________________
Lab:
Urine: Spec. Gr.:
_____________
Alb.______ Sugar______ Drug Screen Performed? ____Y ____N
Other Lab Findings:
_________________________________________________________________________
General Comments:
_________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Employability:
q Medically qualified - No restrictions
q Medically qualified with restrictions
q Medically recommend only after correction or control of condition or defect
q Recommendation is held pending further evaluation or records
Signature:
_________________________________________________________
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Parent category: Medical