Employee Physical Examination

To be completed by physician . Circle or check all that applies

Name _____ _______ ______ ____________ Nationality _________________ D.O.B___________________

Position applied for _______________ Date Hired _________ Department ____________ . Address__________ ______ ____ __________

Home telephone _____ _______ ______ ___________.

Allergies ________ Height _______ Weight _______ Vital Signs Temp._____ Resp.___

BP;L _____/ ____ R_____/ ____ .

CHEST X- RAY

I certify I have examined the named above to the medical standards and have found him / her fit for duty .

Printed name of examining physician _____ _______ ______ ______ Signature _________________

Address of examining physician __________ ______ ____ ____________________

Telephone _____ _______ ______ __________

Exam Date _____________ Employable : Yes ____

Employee Physical Examination - Annual Exam

To be completed by physician

Address__________ ______ ____ _____ Phone _____ _______ ______ __________

Name _____ _______ ______ _______ Nationality _____________ D.O.B __________________

Address __________ ______ ____ ____________ Phone _________________

All lab results are to be forwarded with this form . All abnormal results and physical findings

are comment on general appearance and mental attitude .

Circle or check all that applies .

I certify that I have examined Mrs._____ _______ ______ ______________ and I have found him in normal mental attitude and employable.

Printed name of physician :______ _______ ______ ______________

Signature :

Exam Date :