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The Employee Physical Examination Form is a critical document that addresses the health and medical history of an employee or job applicant. It plays an essential role in determining fitness for duty within various work environments. This form typically begins by collecting the individual's personal information, including their name, date of birth, and job title. Medical history is a significant section, where employees answer yes or no to a variety of health-related questions, ranging from arthritis to substance abuse. Each affirmative response prompts additional explanation. Furthermore, the physical examination portion assesses vital signs such as temperature and blood pressure while evaluating key bodily systems, including lungs, heart, and neurological functions. The examining physician will also review the medical findings, which may include tuberculosis testing and chest X-rays, concluding with a determination of whether the applicant is fit for employment. This thorough approach ensures that both the safety of the individual and the workplace are prioritized.

Employee Physical Example

P 908 312 1423 - www.fivestar.care - F 908 325 1975 216 River Avenue Suite 207 Lakewood, NJ 08701

EMPLOYEE PHYSICAL EXAMINATION FORM

PAGE 1

Last Name:

First Name:

Middle Initial: Today’s Date:

MEDICAL HISTORY: Do you now have, or have you ever had, any of the following:

 

 

 

YES

NO

 

 

YES

NO

 

 

1.

Arthritis / Rheumatism

 

 

10.

Hepatitis A; B; C; other Infections

 

 

 

 

2.

Asthma / Wheezing

 

 

11.

Hernia(s)

 

 

 

 

3.

Back Injury/ Chronic Back Pain

 

 

12.

Hypertension /High Blood Pressure

 

 

 

 

4.

Broken Bones / Fractures

 

 

13. Jaundice / Liver Disease

 

 

 

 

5.

Cancer

 

 

14.

Sinus Trouble / Allergies

 

 

 

 

6.

Diabetes

 

 

15.

Skin Disease

 

 

 

 

7.

Emphysema / Lung Disease

 

 

16.

Stomach Trouble / GI Problems

 

 

 

 

8.

Head Injury / Unconsciousness

 

 

17.

Substance Abuse (History of Drug

 

 

 

 

 

 

 

 

 

or Alcohol Abuse Problems)

 

 

 

 

9.

Heart Disease / Heart Attack

 

 

18.

Tuberculosis or History of Positive

 

 

 

 

 

 

 

 

 

TB Skin Test

 

 

 

I have read the above and declare that I have no injury, illness or ailment other than is specifically noted above. Any falsification or misrepresentation will be sufficient grounds for my release from employment.

Employee’s Signature

Date

Any “YES” answer(s), please explain below.

Put the number (1, 2, 3, etc.) of the YES answer before the explanation:

( Example: “#12. I have been taking medication for high blood pressure since 2007.”)

P 908 312 1423 - www.fivestar.care - F 908 325 1975 216 River Avenue Suite 207 Lakewood, NJ 08701

EMPLOYEE PHYSICAL EXAMINATION FORM

PAGE 2

Last Name:

 

 

 

 

 

 

 

First Name:

 

 

 

 

Middle Initial:

 

Today’s Date:

 

Job Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOB

 

Age

 

Sex

 

HT

 

WT

 

Temp.

Pulse

Resp.

 

B/P

 

Drug/Food Allergies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision: R 20/

 

 

L 20/

 

Pupils: Equal

 

Unequal Glasses/Lenses: Y / N

Hearing: Normal Impaired Hearing Aid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL EXAM

 

 

 

NORMAL

 

ABNORMAL

 

 

 

COMMENTS

1.

General Appearance / BMI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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9.

GU System

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Musculoskeletal Functioning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Full ROM to all extremities? History

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of injury to knees or hips?)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Back / Spine (History of injury?)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Neurological (Gross observation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of gait, coordination, tremors, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Psychiatric (tics, stuttering, nail-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

biting, cognition, orientation, affect,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

obvious personality disorders, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s review of person’s medical history as recorded on reverse side of this form:

PPD / Mantoux Test for Tuberculosis: 1st Step Date:

 

 

 

_ Result:

_ 2nd Step Date:

Result:

 

Chest X-Ray: Date Performed:

 

 

Results:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS APPLICANT IS FIT FOR EMPLOYMENT: YES:

 

 

 

 

NO:

 

 

Deferred for Functional Capacity Evaluation:

 

 

 

 

 

 

 

 

Examining Physician’s Signature

 

Date Physical Examination Performed

Form Characteristics

Fact Title Description
Purpose of the Form The Employee Physical Examination Form is used to assess the health of potential or current employees to ensure they are fit for their job duties.
Medical History Section Employees are required to disclose any past or present medical conditions. This section includes a list of common conditions such as asthma, heart disease, and diabetes.
Signature Requirement The employee must sign the form, confirming the truthfulness of the information provided. This is important to ensure accountability and accuracy.
State-Specific Regulations Different states may have specific requirements for employee physicals. It's essential to refer to state employment laws to ensure compliance.
Visual and Hearing Assessment The form includes evaluations for vision and hearing. Employees must report if they wear glasses, have hearing impairments, or use hearing aids.
Physical Examination Results Healthcare providers complete a section detailing the physical examination results. They note whether aspects of the exam are normal or abnormal.
Additional Explanations If an employee answers "YES" to any medical history question, they must provide further details to clarify their condition.
Fit for Employment Determination The examiner ultimately indicates whether the applicant is fit for employment, which influences hiring decisions.

Guidelines on Utilizing Employee Physical

To ensure all necessary information is accurately provided, follow the steps below to complete the Employee Physical form. After submitting the form, a physician will review your information and conduct a physical examination, which will help determine your fitness for employment. Be clear and precise in your responses for the best outcomes.

  1. Fill in your Last Name, First Name, and Middle Initial at the top of the form.
  2. Write today’s date.
  3. For Medical History, mark "YES" or "NO" next to each listed condition based on your health history.
  4. If any conditions are marked "YES", provide a brief explanation on the same line, noting the corresponding number.
  5. Sign and date the form to confirm that the information is accurate and complete.
  6. On the second page, repeat your Last Name, First Name, and Middle Initial along with today’s date.
  7. Fill in your Job Title, Date of Birth (DOB), Age, Sex, Height (HT), and Weight (WT).
  8. Provide readings for Temp, Pulse, Respiration, and Blood Pressure (B/P).
  9. Indicate any Drug/Food Allergies.
  10. Record your Vision status and note if you wear glasses or lenses.
  11. Mark your hearing status as either Normal, Impaired, or if you use a Hearing Aid.
  12. In the Physical Exam section, assess each area as NORMAL or ABNORMAL.
  13. Gather any additional comments regarding the physical exam if necessary.
  14. Provide details for the PPD/Mantoux Test results, including dates and results.
  15. Complete the section for the Chest X-Ray with the date performed and results.
  16. The examining physician will sign and date the form to confirm the physical examination was performed.

What You Should Know About This Form

What is the purpose of the Employee Physical Examination Form?

The Employee Physical Examination Form is designed to assess the health and fitness of an employee prior to entering or continuing employment. It collects important medical history, ensuring that individuals are capable of performing their job functions safely. This helps employers identify health concerns that could impact job performance or workplace safety.

What information is required on the form?

Employees must provide personal details such as their name, date of birth, and job title. The form also asks about medical history, including previous conditions like arthritis, asthma, or heart disease. Additionally, the physical examination section requires details about vital signs and overall health assessments, including the state of the skin, lungs, heart, and musculoskeletal system.

What should I do if I answer 'YES' to any of the medical history questions?

If you answer 'YES' to any question regarding your medical history, you should provide a detailed explanation in the space provided on the form. It is essential to include the corresponding question number. For instance, if you answer yes to having high blood pressure, you might write “#12. I have been taking medication for high blood pressure since 2007.” This ensures that any potential concerns are properly documented for evaluation.

What happens if there is any misrepresentation on the form?

Falsifying or misrepresenting information on the Employee Physical Examination Form can lead to serious consequences, including termination of employment. It is crucial to be honest and thorough in your responses. Employers rely on this information to maintain a safe and healthy work environment, and any discrepancies may jeopardize that goal.

Who examines the results of the physical examination?

A qualified physician will review the completed Employee Physical Examination Form. This professional assesses both the health history provided and the results from the physical examination. Based on their findings, they will determine if the applicant is fit for employment. Their signature on the form indicates their assessment and recommendation concerning the employee’s fitness for the job.

Common mistakes

Completing the Employee Physical form is an important step in the hiring process, but many individuals make notable mistakes that can affect their employment status. One common mistake is not providing complete information in the medical history section. Omitting details, particularly in response to "YES" questions about past medical conditions, can lead to serious consequences. Honesty is crucial; misrepresenting one’s health can result in job termination.

Another frequent error occurs in the explanation section for "YES" answers. Some people neglect to provide adequate explanations or skip this section altogether. It’s essential for applicants to follow the given example and clearly outline any health issues. Failing to do so can raise red flags for employers, as they may perceive the lack of detail as an attempt to hide relevant information.

The accuracy of personal information should not be overlooked. Mistakes in filling in details like birthdate, job title, or contact information can create confusion. These seemingly minor errors may complicate the hiring process and lead to delays in finalizing employment. Accuracy is crucial for ensuring proper communications and record-keeping.

Individuals sometimes also disregard the need for clinical measurements like height, weight, and vital signs. Incomplete entries can affect the assessment of physical fitness for the intended job. Employers rely on this data to evaluate whether a candidate is a suitable fit for the physical demands of a position.

Moreover, errors can arise from using inconsistent terminology when describing medical conditions. Medical terms can vary in definition and may lead to misunderstanding. For example, someone might mention "high blood pressure" without specifying if they've received treatment for it. Consistent terminology aids in creating a clearer medical profile.

Lastly, some applicants fail to understand the significance of their physician's review. The section where a physician evaluates the medical history and performs a physical examination is crucial. Not ensuring that this is completed properly can mean an incomplete evaluation. Employers look for validation from a qualified physician to ensure the candidate meets health requirements.

Documents used along the form

The Employee Physical Examination Form is an essential document in the hiring process, helping employers ensure that candidates are physically capable of performing job duties. Alongside this form, several other documents complement the evaluation of an employee's health and fitness for work. Here are five documents commonly used in conjunction with the Employee Physical Form:

  • Job Description: This document outlines the specific responsibilities and requirements of the position. It helps both the employer and the employee understand what physical abilities and health considerations must be taken into account during the physical examination.
  • Pre-Employment Health Questionnaire: A detailed survey that candidates complete prior to the physical exam. This questionnaire covers a broad range of health-related questions, allowing employers to gather relevant medical history that can be evaluated alongside the physical examination results.
  • Release of Information Form: This form authorizes healthcare providers to share medical records and information with the employer. It is important for verifying the accuracy of health claims made by the prospective employee and ensures compliance with privacy regulations.
  • Fitness for Duty Certification: After the completion of the physical examination, this certification signifies that an employee is physically qualified to perform their job. It is often required for roles that demand specific physical capabilities or health standards.
  • Drug Testing Consent Form: Many companies require drug screening as a part of the hiring process. This form gives consent for the employee to undergo testing for prohibited substances, ensuring a safe and drug-free workplace.

Each of these forms plays a significant role in creating a safe and healthy work environment. Together, they provide a comprehensive assessment of an employee’s physical readiness for the challenges of their job. By using these documents in tandem, employers can make informed decisions while also respecting the rights and privacy of their employees.

Similar forms

  • Medical History Questionnaire: This document gathers essential health information from the employee, similar to the Employee Physical form. It emphasizes personal health conditions and any past medical issues that could impact job performance or safety.
  • Pre-Employment Screening Form: Like the Employee Physical form, this screening assesses an applicant’s fitness for work. It usually reviews medical fitness and any potential health risks associated with the job responsibilities.
  • Workers' Compensation Claim Form: This form is similar as it requires detailed medical history and current health conditions. Both documents focus on identifying any medical issues that could relate to workplace safety or injury.
  • Post-Offer Medical Examination Form: This document assesses an individual’s physical condition after a job offer, just like the Employee Physical form. It ensures that the candidate can perform required duties without compromising health or safety.
  • Health and Safety Compliance Form: This form ensures adherence to workplace health standards, aligning with the Employee Physical form’s purpose. It highlights any abnormalities in health that could affect workplace safety and performance.

Dos and Don'ts

When completing the Employee Physical form, it is essential to ensure that the information provided is accurate and clear. Here are six things you should and shouldn't do:

  • Do: Read the entire form carefully before filling it out.
  • Do: Provide detailed explanations for any "YES" answers in the medical history section.
  • Do: Ensure that your signature and date are included before submitting the form.
  • Do: Double-check your personal information for accuracy.
  • Don't: Leave any sections blank; each question should be answered.
  • Don't: Provide misleading or false information, as this may jeopardize your employment.

Misconceptions

Misunderstandings can arise around the Employee Physical form. Here are ten common misconceptions, along with clarifications.

  1. It's only for physical jobs. Many believe that the physical examination is only necessary for labor-intensive positions. In reality, all job roles can benefit from a health assessment to ensure that employees are fully capable of performing their tasks safely.
  2. The medical history questions are optional. Some think that they can skip answering questions about their medical history. However, providing complete and accurate information is crucial for identifying potential health risks.
  3. You can falsify information without consequences. It's a common misconception that inaccurate information will go unnoticed. In fact, misrepresentation can lead to termination, as it violates employment agreements.
  4. Employee privacy is not protected. Many believe that their health information will be publicly shared. In truth, confidentiality is paramount, and your information will be kept private by the employer.
  5. Only serious health issues need to be disclosed. Some feel inclined to omit minor ailments. However, even small issues can impact overall performance and should be reported.
  6. It's not necessary to see a doctor for this exam. Employees may assume that a physical form can be filled out without professional input. In fact, a physician's assessment is typically required to ensure accuracy of the medical findings.
  7. The form is only relevant during hiring. There’s a belief that the Employee Physical form is only needed when starting a job. Many employers require periodic physical exams to monitor employee health over time.
  8. You don't need to bring documentation. Some individuals think that they can just fill out the form without supporting documents. It is often necessary to provide medical records or additional documentation supporting your health history.
  9. The results are available immediately. There’s an assumption that you will receive results on the same day. Many times, the examination results require time for review and testing before sharing with the employee.
  10. Only the physician checks the form. Some assume that only the examining physician reviews the form. However, human resources also assess the information to determine employment eligibility.

Understanding the facts about the Employee Physical form can lead to a smoother process and better health outcomes for everyone involved.

Key takeaways

Here are key takeaways for filling out and using the Employee Physical form:

  • Personal Information: Ensure all personal details, including last name, first name, middle initial, today’s date, and job title, are filled out accurately at the top of the form.
  • Medical History: Review the medical history section carefully. Answer the questions regarding your health honestly, marking 'YES' or 'NO' as applicable.
  • Explanation Required: If you answer 'YES' to any questions in the medical history section, provide a detailed explanation in the space provided. Use the number from the question for clarity.
  • Employee Signature: Sign and date the form, confirming that the information is accurate and complete. Understand that any misrepresentation can lead to employment consequences.
  • Physical Examination: The physician conducting the exam will assess various health indicators. Ensure you understand what they are examining and ask questions if necessary.
  • Document Results: Results such as blood pressure, temperature, and other physical exam results will be recorded. Make sure this information is accurate and clear.
  • Final Assessment: The examining physician will recommend whether the applicant is fit for employment based on the findings. Ensure you receive a copy of the final assessment for your records.