Pre-Employment/job Placement Medical Questionnaire Form Page 2
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1
2Physician Pre-Employment / Pre-placement Examination
Name _________________________________________________________ DOB: _______________
Age: ______________
Ht _________ Wt __________ P ______ R ______
BP #1 - ______/______
#2 - ______/______
VISUAL ACUITY
Distance
Near
Actual – uncorrected
Right
20 /
Left
20 /
Right
20 /
Left
20 /
Corrected
Right
20 /
Left
20 /
Right
20 /
Left
20 /
Abnor
Not
PHYSICAL EXAMINATION
Normal
mal
Examined
Explain any abnormals by number
1. Head
2. Eyes – PERRL, EOMI
3. Ears – TM’s & canals normal
4. Nose – patent w/o drainage
5. Throat – clear
6. Neck – Nl ROM, supple, no
bruits
7. Lymph nodes – none palpable
8. Thyroid – not enlgd or tender
9. Skin – no rashes or icterus
10. Lungs – clear
11. Heart – RRR w/o murmur, no
evidence of enlgmt
12. Chest – no deformity or
tenderness
13. Abdomen – non-tender, no
masses/organomegaly, no
bruits
14. Hernia – no umbil or inguinal
Additional Findings
15. Genitalia – normal for age
16. Rectal – no hemorrhoids
17. Upper Extrem – full ROM
without pain, nl strength
18. Lower Extrem – full ROM
without pain, nl strength
19. Back/Spine – ROM WNL, no
palplable tenderness, no
visible deformity
20. Reflexes – symmetric &
normal
21. Psych – no obvious
abnormality
After examination and review of history on reverse, my impression is:
normal exam
Job description reviewed – no contraindications to employment in this job.
____________________________________________________________________________________________________
Recommendations: _______________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Examining Provider ________________________________ Signature ______________________________ Date ____________
** Unless you indicate otherwise, only the IMPRESSION and RECOMMENDATIONS from this visit will be released to your
prospective employer. Please indicate below if you wish to release the entire report (front & back pages) to your employer.
I hereby indicate my wishes to have the Hutchinson Clinic and the Examining Provider release a full copy of this report
to my employer
(insert name of employer ______________________________________)
Name (
) _____________________________________ Signature ______________________________ Date _______
please print
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Parent category: Life