Pre-Employment Physical Exam Form - Tpf Nursing
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1PRE-EMPLOYMENT PHYSICAL EXAM
TO BE COMPLETED BY A LICENSED MD,DO, NP,PA,CNM
Applicant
Address
DOB______________
_______________________________________
___________________________
TO PHYSICIAN: A health examination is required for the above named person. Please enter details of all requested
information. LABORATORY REPORTS MUST BE ATTACHED. Incomplete or illegible information may be rejected
Does applicant have any personal health considerations that may impact his/her ability to satisfactorily perform the duties given
on a particular assignment (including but not limited to habituation or addiction to depressants, stimulants, narcotics, alcohol or
other drugs which could alter his/her behavior? NO____YES_____ If yes, please de-
scribe:______________________________
Is Applicant in good health without restrictions or limitations? NO _____
YES _____
MEDICAL HISTORY:
Any major illness or health impairment
_____________________________________________________________________
Hospitalization / Serious injury ___________________________________________________________________________
Any significant finding in patient’s past history? _____________________________________________________________
Any significant finding in patient’s family’s health history_____________________________________________________
Allergy____________________ Latex / non-medication allergies: NO___ YES___ If yes, please specify:________________
Medication Currently being taken: _________________________________________________________________________
PHYSICAL EXAMINATION (notate all spaces, draw-through lines are not acceptable):
Height:
Weight:
BP:
Pulse:
Respiration:
Temp:
_________
_________
_________
_________
_________
_________
Examined:
Normal Abnormal
Normal Abnormal
Normal Abnormal
Normal Abnormal
General Appearance ______ ______ HEENT ______ ______ Breasts
______ ______ Abdomen
______ ______
Neurological Exam ______ ______ Heart
______ ______ Lymph Nodes ______ ______ GU Exam
______ ______
Musculoskeletal
______ ______ Lungs ______ ______ Pelvic Exam ______ ______ Rectal Exam ______ ______
Extremities
______ ______ Neck
______ ______ COMMENTS:________________________________________
Immunizations: **(Please include lab report with values)**
Two (2) PPD Tests (Mantoux) or one (1) Interferon Gamma Release Assay (e.g. Quantiferon) required:
Quantiferon
PPD Test 1:
PPD Test 2:
(of other IGRA):
(w / in 12 months)
(w /in 3 months)
Date: __________
__________
__________
__________
__________
Date placed:
Date read:
Date placed:
Date read:
Result:_____________
Results: ______ mm
NEG POS
Results: ______ mm
NEG POS
___________
___
___
___________
___
___
If PPD positive, earliest date of + PPD?
History of BCG?Y
N
Date
Was Tb prophylaxis taken?N
Y
___________
________________________
What medication? __
____________ How long? ________ In your opinion what caused + PPD?
Chest X-Ray (for + PPD or positive IGRA) Date: _____________ Result:_____________ (Chest X-ray must be attached)
Rubella antibody titer:
Date: _________
OR
_______
(Attach Lab report)
vaccine date: ________
Rubeola antibody titer: ______ Date: _________
OR
(Attach Lab report)
2 doses of live vaccine dates:(1) _______ (2) _______
Exempt if DOB before 1957
Mumps antibody titer:
Date: _________
OR
_______
(Attach Lab report)
2 doses of live vaccine dates: (1) _______ (2) _______
Varicella antibody titer:
Date: __________
_______
(required in all cases)
(Attach Lab report) Vaccination dates: (1) _______ (2) _______
Hepatitis B surface antibody titer: __________
Vaccine dates:(1)________(2)________(3)________
(Attach Lab report)
(or Declination)
Tdap vaccine (within 10 years) Date: __________ Lot #: _____________
Flu Vaccine
Date: __________ Lot#: _____________ Mfr: _____________ Expiration: __________
___________________________________
_____________________
Physician Signature
Date
License number: ____________________
1
Physician Name printed or stamp:
_____________________________________
State: ____________________
Telephone: _________________________ Address:
____________________________________________________________
TPF Nursing 121 West 11th Street, NY,NY 10011* Telephone (212) 219-2677* (800) 243-6449 * Fax (212) 431-2594*
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