Employee Physical Examination Questionnaire
Staff Personal Details
Staff Name
First Name
Last Name
Gender
Male
Female
Job Title
Ex: Marketing Specialist
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Staff Medical Details
Height
Ex: 1.65 cm
Weight
Ex: 55 kg
Tobacco Use
Current
Former
None
Past Medical History
Hypertension
Heart Disease
Chronic Lung Disease
Alcohol Abuse
Allergies
Hepatitis
Diabetes
Physical Disabilities
None of All
Other
Please provide a more detailed explanation
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Date
-
Month
-
Day
Year
Date
Examiner Name
First Name
Last Name
Examiner Signature
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