Pre-Employment Physical Form - H&c Nursing Care & Staffing Agency
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2525 Highland Boulevard Suite 105 Coatesville, PA 19320 (215) 604-1562
PRE-EMPLOYMENT PHYSICAL
Name: _________________________________________________________ Male
Female
Address: _______________________________________________________
Date of Birth: ___________________
Telephone#: ____________________________________
SS# (Last 4 digits):
___________________
Medical Practitioner: Please complete the following:
Height: _________
Weight: _________
BP: _________
T.P.R _________
1.
Immunizations and Lab Tests:
* PPD # 1(Mantoux)
Pos
Neg
Date Implanted: ____________
Date Read: ________________
* PPD # 2: (Mantoux)
Pos
Neg
Date Implanted: ____________
Date Read: ________________
: (
)
: __________________
Chest X-ray
Pos
Neg
Date
If PPD is positive
(Attach lab report)
*
Rubella
Pos
Neg
Titer: _______ Date: ________
: _______
: _______
* Rubeola
Pos
Neg
Titer
Date
(if born after 12/31/56)
*
: _______
: _______
MMR Vaccine
Date
Date
(alternate for Rubella & Rubeola)
*
: ____________
Varicella Vaccine
Date
*
Hepatitis B Vaccine
#1 Date: _______ #2 Date: _______ #3 Date: ________Titer: ________
(optional)
Medical Exemption from Influenza Vaccine:
Yes
No
(complete attached exemption form)
(complete information below)
*
(
.)
_______________
Seasonal Influenza Vaccine
Date:
for applications from Sept. to Mar
Type of vaccine: _________________________________
Dose: __________________________
Manufacturer & Lot #: ____________________________
Site of Administration: ____________
Person administering the vaccine:
Name: ___________________________________________________________________________
Last Name
First Name
Signature: ____________________________________
Title: _____________________________
Reactions (if applicable): _____________________________________________________________
2.
:
Review of Systems
Cardiovascular ______________
Muscular
______________
Digestive
______________
Nervous
______________
Endocrine
______________
Reproductive
______________
Excretory
______________
Respiratory
______________
Immune
______________
Skeletal
______________
Present Medication(s): Yes
No
(
If yes, attach list of medications, dosages, and purpose)
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Parent category: Medical