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_________________