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The Employee Physical Examination Form serves as a critical tool for employers and employees alike, ensuring that individuals are fit for the demands of their job roles. This comprehensive document gathers essential information about an employee's medical history, including past and current health conditions such as arthritis, asthma, and heart disease. It also assesses vital signs and physical health indicators, including height, weight, temperature, and blood pressure. Additionally, the form includes a section for drug and food allergies, as well as a vision and hearing assessment. Employees must sign the form, affirming the accuracy of their medical disclosures, with a clear warning that any misrepresentation could lead to termination. The examination culminates in a physician’s review, which determines the employee's fitness for duty and may require further evaluations if necessary. By systematically collecting this information, the form not only protects the health of the workforce but also supports employers in making informed hiring decisions.

Preview - Employee Physical Form

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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Lungs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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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

Document Specifics

Fact Name Details
Purpose of the Form The Employee Physical Examination Form is designed to assess the medical fitness of an employee for their job role.
Medical History Section This section requires employees to disclose any past or present medical conditions, which may affect their ability to perform job duties.
Legal Implications Providing false information on this form can result in termination of employment, as stated in the declaration section.
State-Specific Requirements In New Jersey, the form must comply with the New Jersey Administrative Code, specifically regarding medical examinations in the workplace.
Physical Examination Components The form includes various physical assessments, such as checking general appearance, lungs, heart, and neurological functions.
Allergy Information Employees must disclose any drug or food allergies, which is crucial for ensuring their safety in the workplace.
Vision and Hearing Assessment Employees are evaluated for vision and hearing capabilities, which may be essential depending on their job responsibilities.
Physician's Review A licensed physician must review the completed form, ensuring a professional assessment of the employee's health status.
Fit for Employment The physician must indicate whether the applicant is fit for employment, which can influence hiring decisions.
Follow-Up Tests Results from additional tests, such as the PPD/Mantoux test for tuberculosis, are documented to ensure comprehensive health screening.

Employee Physical: Usage Instruction

Completing the Employee Physical form is an essential step in ensuring that all necessary medical information is accurately recorded. Follow these instructions carefully to fill out the form correctly. Once completed, the form will be reviewed by the appropriate personnel to assess fitness for employment.

  1. Begin by filling in your Last Name, First Name, and Middle Initial at the top of the form.
  2. Enter Today’s Date in the designated space.
  3. In the MEDICAL HISTORY section, answer each question with a YES or NO. Be honest and thorough.
  4. If you answer YES to any question, provide an explanation in the space provided below the questions. Use the corresponding number from the list.
  5. Sign and date the form where it states Employee’s Signature.
  6. On the second page, fill in your Job Title, Date of Birth, Age, and Sex.
  7. Record your Height (HT), Weight (WT), Temperature, Pulse, Respiration, and Blood Pressure (B/P) in the appropriate fields.
  8. Indicate any Drug/Food Allergies you may have.
  9. Assess your vision and hearing. Fill in the vision details for each eye and check the appropriate box for hearing.
  10. In the PHYSICAL EXAM section, mark NORMAL or ABNORMAL for each item listed. Provide comments where necessary.
  11. Have the examining physician review your medical history and complete the PPD / Mantoux Test and Chest X-Ray sections, including dates and results.
  12. Finally, the physician will indicate if you are FIT FOR EMPLOYMENT and sign the form.

Learn More on Employee Physical

  1. What is the purpose of the Employee Physical Form?

    The Employee Physical Form is designed to assess the health and fitness of employees before they begin work. It helps identify any medical conditions that may affect job performance or safety. Completing this form is crucial for ensuring a safe working environment for everyone.

  2. Who needs to fill out the Employee Physical Form?

    All employees are required to fill out the Employee Physical Form before starting their job. This includes new hires and, in some cases, current employees who may be transitioning to a new role or returning after a medical leave.

  3. What kind of medical history information is required?

    The form asks for information regarding various medical conditions, such as arthritis, asthma, heart disease, and diabetes. You will need to answer whether you currently have or have ever had any of these conditions. If you answer "yes" to any question, you should provide additional details.

  4. What happens if I answer "yes" to any medical history question?

    If you answer "yes," you must explain your condition in the space provided on the form. For example, if you have high blood pressure, you might write, “#12. I have been taking medication for high blood pressure since 2007.” This information helps the employer understand your health better.

  5. What physical examinations are included in the form?

    The form includes a range of physical examinations, such as assessing general appearance, skin condition, heart function, and musculoskeletal health. The examining physician will check for any abnormalities and provide comments where necessary.

  6. How is the information from the form used?

    The information collected from the Employee Physical Form is used to determine if you are fit for employment. It helps employers ensure that employees can perform their job duties safely and effectively.

  7. What if I have a medical condition that affects my ability to work?

    If you have a medical condition that may impact your work, it’s essential to disclose this on the form. Employers may provide accommodations or adjustments to help you perform your job safely.

  8. What should I do if I have concerns about privacy?

    Your health information is confidential. Employers are required to handle this information with care. If you have concerns, discuss them with your HR department before filling out the form.

  9. Is there a deadline for submitting the Employee Physical Form?

  10. What if I need assistance filling out the form?

    If you need help, reach out to your HR department or the person who provided you with the form. They can guide you through the process and answer any questions you may have.

Common mistakes

Filling out the Employee Physical form is an important step in the hiring process. However, many individuals make mistakes that can lead to complications later. One common mistake is leaving out essential personal information. For instance, not providing the last name or first name can cause delays in processing the form. Always ensure that all sections requiring personal identification are completed accurately.

Another frequent error is failing to answer the medical history questions honestly. When asked about past health issues, some people might skip questions or select "NO" even when they have relevant conditions. This can result in serious consequences, including potential termination if the employer discovers the misrepresentation. It is crucial to be truthful about any medical history, as it can affect job performance and safety.

Some individuals also neglect to explain their "YES" answers in the designated section. This omission can create confusion for the reviewing physician. Providing clear explanations helps the medical professional understand the context of the health issues and assess fitness for employment accurately. Always remember to include the corresponding number and details for each "YES" response.

Another mistake involves overlooking the section for drug and food allergies. Failing to disclose allergies can put an employee's health at risk, especially in environments where certain substances may be present. It is vital to fill out this section thoroughly to ensure a safe working environment.

Finally, people often forget to sign and date the form. Without a signature, the form may be considered incomplete. This simple step is essential for confirming that the information provided is accurate and that the individual understands the implications of any misrepresentation. Always double-check that the signature and date are included before submitting the form.

Documents used along the form

When an employee undergoes a physical examination, several other forms and documents are typically utilized to ensure a comprehensive assessment of their health and fitness for work. These documents help employers maintain compliance with health regulations and provide necessary information for decision-making. Below is a list of commonly associated forms.

  • Medical History Questionnaire: This document gathers detailed information about an employee's past and present health conditions, medications, and family medical history to provide context for the physical examination.
  • Consent Form: Employees sign this form to grant permission for the examination and any necessary tests, ensuring that they understand the procedures involved.
  • Occupational Health Questionnaire: This form focuses on health issues related to specific job duties, assessing risks associated with the employee's role and the work environment.
  • Drug Screening Consent Form: Employees may be required to consent to drug testing as part of the hiring process. This form outlines the procedures and implications of the testing.
  • Vaccination Records: Documentation of immunizations is often required, especially for positions in healthcare or other fields where exposure to infectious diseases is a concern.
  • Return-to-Work Form: After an employee has been absent due to health issues, this form confirms their fitness to return to work, often including a physician's approval.
  • Workplace Safety Acknowledgment: This document outlines safety protocols and expectations, ensuring that employees understand their responsibilities in maintaining a safe work environment.
  • Functional Capacity Evaluation (FCE): An FCE assesses an employee's ability to perform job-related tasks, providing valuable information about their physical capabilities and limitations.

These forms collectively enhance the understanding of an employee's health status, facilitating a safer and more compliant workplace. Proper documentation is crucial for both employee well-being and organizational accountability.

Similar forms

The Employee Health Questionnaire serves a similar purpose to the Employee Physical Examination Form by collecting essential medical history from employees. This document typically includes questions about past and present health conditions, medications, and any history of chronic illnesses. Like the Employee Physical Form, it aims to identify potential health risks that may affect job performance or workplace safety. Both documents require the employee's signature to confirm the accuracy of the information provided, emphasizing the importance of honesty in the employment process.

The Pre-Employment Medical Assessment is another document that aligns closely with the Employee Physical Examination Form. This assessment evaluates an individual's overall health before they begin a new job. It often includes a physical examination, medical history review, and sometimes additional tests, such as blood work or vision tests. Similar to the Employee Physical Form, it assesses whether the candidate is fit for the specific demands of the job, ensuring that the employer can make informed hiring decisions based on health considerations.

The Occupational Health Questionnaire is also comparable to the Employee Physical Examination Form. This document focuses on identifying health issues related to specific job functions or environments. It may ask about exposure to hazardous materials, physical demands of the job, and any pre-existing conditions that could be exacerbated by the work environment. Both forms aim to protect employee health and safety while ensuring compliance with workplace regulations.

Finally, the Fitness for Duty Evaluation is akin to the Employee Physical Examination Form in that it assesses an employee's ability to perform their job safely and effectively. This evaluation is often conducted after an injury or prolonged absence due to illness. It includes a review of medical history, a physical examination, and sometimes functional testing. Like the Employee Physical Form, it ensures that employees are capable of fulfilling their job responsibilities without posing a risk to themselves or others in the workplace.

Dos and Don'ts

When filling out the Employee Physical form, it’s essential to approach the task with care and attention. Here’s a helpful list of things to do and avoid, ensuring that your submission is accurate and complete.

  • Do provide accurate personal information, including your full name and today's date.
  • Do read each medical history question carefully before answering.
  • Do answer truthfully, especially regarding any medical conditions or past injuries.
  • Do explain any "YES" answers in detail, using the corresponding numbers for clarity.
  • Do review the form for completeness before submitting it.
  • Don't leave any sections blank; every part of the form is important.
  • Don't provide false information or exaggerate your medical history.
  • Don't rush through the form; take your time to ensure accuracy.
  • Don't forget to sign and date the form at the bottom.
  • Don't ignore any instructions provided by the examining physician.

By following these guidelines, you can help ensure that your Employee Physical form is filled out correctly, facilitating a smoother process for your employment evaluation.

Misconceptions

There are several misconceptions about the Employee Physical form that can lead to confusion among employees and employers alike. Here are five common misunderstandings:

  • It's only for new hires. Many believe that the Employee Physical form is required only for new employees. However, it can also be necessary for current employees, especially when there are changes in job roles or health status.
  • It is a complete medical evaluation. Some think that the Employee Physical form serves as a comprehensive medical examination. In reality, it primarily focuses on specific health conditions relevant to job performance and safety.
  • All 'YES' answers disqualify employment. A common belief is that any affirmative response on the form will automatically disqualify an applicant. This is not true. Each case is evaluated individually, considering the nature of the condition and its impact on job performance.
  • It is only about physical health. Many assume the form only addresses physical health issues. However, it also includes questions about mental health, substance abuse, and other factors that can affect an employee’s ability to perform their job safely.
  • Employees can skip questions. Some individuals think they can leave questions unanswered without consequences. In fact, all questions should be answered fully, as incomplete forms may delay the hiring process or lead to employment complications.

Key takeaways

When filling out and using the Employee Physical form, it's essential to keep a few key points in mind. This form plays a critical role in ensuring the health and safety of both employees and the workplace.

  • Be Honest and Thorough: Provide accurate information regarding your medical history. Any "YES" answers must be explained in detail. Misrepresentation can lead to serious consequences, including termination of employment.
  • Understand the Importance: The form is not just a formality. It helps employers assess your fitness for the job and identify any potential health issues that may affect your work performance.
  • Review Before Submission: Double-check all entries for accuracy. Ensure that all sections, especially the medical history and physical examination results, are filled out completely and correctly.
  • Communicate with Your Physician: If you have any medical conditions or concerns, discuss them with the examining physician. Their insights can help provide a clearer picture of your health status and any necessary accommodations.