Medical Examination Form Page 2
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2V. PHYSICAL EXAMINATION:
General Appearance:
_______________
Temperature:
Height:
_______________
Weight:
_________
Body Mass Index:
______________
BP:
_______________
PR:
_________
RR:
______________
Visual Acuity:
_______________
OD
_________
OS
______________
With Objective Findings ?
Yes
No
Remarks
Head
_______________________
Eyes & Ears
_______________________
Nose & Sinuses
_______________________
Mouth
_______________________
Neck, Nodes & Thyroid
_______________________
Chest & Breast
_______________________
Heart & Lungs
_______________________
Abdomen
_______________________
Pelvic Exam
_______________________
Skin & Glands
_______________________
Extremities
_______________________
Neurological Exam
_______________________
VI. OTHER EXAMINATIONS
With Objective Findings?
Yes
No
Remarks
Chest X-ray
______________________
Urinalysis
______________________
CBC
______________________
ECG
______________________
Blood Chemistry
______________________
Fecalysis
______________________
VII. IMPRESSION:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
VIII. RECOMMENDATIONS
___________________________________________________________________________________________
___________________________________________________________________________________________
Pre-employment Classification:
_____A. Medically Fit for Employment
_____B. Medically Ft for Employment with Minimal Findings
_____C. With Obvious Defect but Maybe Employed at Management’s Discretion
_____D. Medically Unfit for Employment
_____E. With Pendings: ________________________________________________________________________
Medical Evaluation Decision:
_____For Completion of Medical Evaluation
_____Approved for Membership
_____Disapproved for Membership
_____To Sign Waiver for _______________________________________________________________________
Medical Examiner: ________________________________________
_______________________
License No:
________________________________________
Clinic Operations Manager
Date Examined:
_________________________________________
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