Post-Offer & Annual Physical Examination -Template Page 2
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2(Physical Examination continued)
Height (in stockings)
Weight (indoor clothing)
Temperature
Pulse ______________
Respiration
Blood Pressure
Has no current clinical diagnosis of high blood pressure likely to interfere with his or her ability to drive a
.
school bus safely (if blood pressure is consistently over 160/90 mm Hg., further test may be necessary)
Hearing: Distance Test: Left Ear
Right Ear
OR
Audiometric:
Left Ear
Right Ear __________
(Pure tone averages for 500, 1000 & 2000 Hz)
Vision: (State methods used)
Distant
Near
Right
Corrected Right
Right
Corrected Right __________
Left
Corrected Left
Left
Corrected Left __________
Color ________________________________________________________________________________________________________
Skin
Head
Neck ________________________________
Nose
Mouth
Teeth ________________________________
Throat
Thyroid ________________________________________________
Thorax: Heart
Lungs
Chest X-Ray Results ________________________________
(When deemed advisable by physician)
(Reexamine heart after exercise in those over 35) _____________________________________________________________________________________
Vascular System
Abdomen
Hernia __________________________
Musculo-Skeletal
Arms
Legs
Digits _________________________________
Back
Joints
Neurological ___________________________
Recto-genital studies: Diseases or conditions causing discomfort should be evaluated carefully to determine the extent to which the condition
might be handicapping while lifting, pulling, or during periods of prolonged driving that might be necessary as part of the driver's duties.
Rectal
Genitalia __________________________________________________
Laboratory Findings
Urinalysis: Spec. Gr.
Albumin
Sugar __________________________
Tuberculosis Skin Test: Positive
Negative ____________________________________________
(Required of all new drivers and others when deemed advisable by physician)
Physician's comments ________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
This is to certify that I have this day, Date of Exam,____________________ examined _________________________________
and find him/her
Qualified as a School Bus Driver
Not Qualified as a School Bus Driver
_________________________________________________________
Examining Physician's MD/DO Signature
If signed by PA or NP complete the following:
_________________________________________________________
Georgia Medical License Number
__________________________________________________________________
Print Name of Supervising/Delegating Physician
_________________________________________________________
__________________________________________________________________
Signature of PA or Cert. Nurse Practitioner
Medical License Number for Supervising/Delegating Physician
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