Preplacement Medical/physical Assessment Form - Howard County General Hospital

Preplacement Medical/physical Assessment Form - Howard County General Hospital - Page 3

MALES ONLY

Do you self-testicular exam? _____________

How Often? ____________

___

Discharge from penis

___

Difficulty start stream

___

Testicular swelling or pain

___

Impotence

GENERAL HEALTH REVIEW

Please check any Present Condition:

General

Head/Neck

___

Allergies

___

Headache/Migraine

___

Sleep Disturbances

___

Limited Movement

___

Excessive Thirst

___

Lumps

Eyes

Ears

___

Double Vision

___

Hard of Hearing

___

Blurred Vision

___

Discharge

___

Eye Pain

___

Ringing

Nose

Mouth/Throat

___

Discharge

___

Bleeding Gums

___

Obstruction

___

Sore Tongue

___

Frequent Colds

___

Dental Pain

___

Excessive Bleeding

___

Difficulty Swallowing

___

Hoarseness

Gastro-Intestinal

Cardio-Respiratory

___

Nausea/vomiting

___

Shortness of breath

___

Abdominal pain

___

Chest pain

___

Rectal Pains

___

Heaviness in chest

___

Rectal Bleeding

___

Frequent cough

___

Spitting up blood

___

Wheezing

___

Extreme fatigue

Genito-Urinary

Skin

___

Frequent Urination

___

Itching

___

Painful Urination

___

Rashes

___

Blood in Urine

___

Lumps

___

Eczema

___

Psoriasis

___

Scaling

Musculo-Skeletal

General Nervous System

___

Frequent dislocations of a joint

___

Convulsions

___

Backaches

___

Dizziness

___

Joint swelling or pain

___

Numbness or Tingling

___

Painful feet or ankles

___

Muscle Weakness

___

Limp

___

Memory Loss

___

Torn ligaments

___

Loss of Balance

___

Inability to assume certain positions

___

Depression

___

Blackouts

I certify that all information contained in these personal medical history is true. I authorize its investigation and agree that any

misleading or false statements would render my employment application void, and would be sufficient cause for immediate dismissal in

the event of employment. I understand that this physical assessment does not duplicate or replace the physical done by my physician.

____________________

___________________________________

Date Signed

Signature of Applicant

Preplacement Medical/physical Assessment Form - Howard County General Hospital - Page 3

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