Employee Physical Examination And Medical History

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WINNING WHEELS
EMPLOYEE PHYSICAL EXAMINATION
Last Name: _______________________ First Name: _____________ Physician: ____________Date:____
Age: _____ Wt.:_____ Ht.: _____ BP: _____ Temp.: _____ Pulse: _____ Resp.: _____
Person Free of Communicable Disease?
Yes
No
If no, please explain________________________
MEDICAL HISTORY:
Hepatitis
Yes
No
High Blood Pressure
Yes
No
Diabetes
Yes
No
Mental Illness
Yes
No
Tuberculosis
Yes
No
Heart Trouble
Yes
No
Epilepsy
Yes
No
Cancer
Yes
No
If yes is answered to any of the above conditions, please explain ______________________________________
PHYSICAL EXAMINATION
General Appearance: (Including skin) ___________________________________________________________
History of Any Major Medical Conditions
Yes
No If Yes, Explain ____________________________
History of Mental Illness
Yes
No If Yes, Explain __________________________________________
History of Any Major Surgeries
Yes
No If Yes, Explain ____________________________________
Head (Eye, Ear, Nose, Throat, Teeth) ___________________________________________________________
History of Head Aches?
Yes
No If Yes, Explain ___________________________________________
Neck _____________________________________________________________________________________
History of Neck Pain?
Yes
No If Yes, Explain ____________________________________________
Back and Spine (Including Test for Flexibility) ___________________________________________________
History of Back or Spine Problems?
Yes
No If Yes, Explain _________________________________
Chronic Back Pain?
Yes
No If Yes, Explain ______________________________________________
Lungs/Chest _______________________________________________________________________________
Persistent Cough?
Yes
No If Yes, Explain _______________________________________________
Past Chest X-Ray? __________ Date Reason ____________________________________________________
Abdomen _________________________________________________________________________________
History of Hernia(s)?
Yes
No If Yes, Explain _____________________________________________
History of Abdominal Pain?
Yes
No If Yes, Explain _______________________________________
History of Heart Trouble?
Yes
No If Yes, Explain _________________________________________
Musculoskeletal ____________________________________________________________________________
Feet ______________________________________________________________________________________
History of Any Joint Pain (Wrist, Ankle, Knee)?
Yes
No If Yes, Explain _______________________
PHYSICIAN SIGNATURE _____________________________________ DATE __________________
For Office Use Only
Results of Drug Screening: _____________________ Date:________________ Signature_________________

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