Best Choice Pre-Employment Physical Page 2
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2Name: _____________________________________________
SS# (Last 4 digits): _______________
2. Past Medical History
YES
NO
Any serious problems, surgery
Tuberculosis
Diabetes
Mental/Behavioral Disorder
Cardiovascular Disease
Hypertension/Hypotension
Asthma
Epilepsy/Seizure Disorder
Cancer
Kidney Disease
Drug/Alcohol Abuse
Allergies
Other ________________________________
3. Tuberculosis (TB) Questionnaire/Screening
YES
NO
Exposure to TB at Work/Home
Positive Chest X-Ray
Unintended Weight Change (+/- 10 lbs)
Persistent Cough
Conversion to Positive PPD
Low Grade Fever
Unexplained fatigue
Blood Streaked Sputum
Active TB
Night Sweats
Loss Appetite
Clear, Yellow or Dark Sputum
I certify that I have examined the above-named individual and found him/her to be free of any addiction/ habituation to
depressants, stimulants, narcotics, illegal drugs, or alcoholic substances.
Yes
No
I certify that I have examined the above-named individual and found him/her to be:
[
] Fully Employable – No limitations
[
] Employable – Suggest Follow Up and/or completion of: ____________________________________
[
] Not Currently Employable – Recommend Additional Testing /Treatment and/or Follow Up as soon as
possible for: ____________________________________________________________________________
Medical Practitioner’s Signature ___________________________________
Date: ______________
Address: _________________________________________
Phone #: __________________________
Title: ____________________________________________
Office Stamp:
License #: ________________________________________
Please note:
•
Physical is not acceptable without Medical Practitioner’s stamp; which includes practitioner’s name, address, phone #
and license #. Form must be stamped and signed.
•
If applicable, a copy of Chest X-Ray Report must be attached
•
Toxicology Screening will be scheduled by Best Choice Home Health Care.
Please turn over
1/21/11
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Parent category: Medical