Pre Employment Physical Form
Personal Information
Name
*
First Name
Last Name
ID Number
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Height
*
Weight
*
Primary Physician
*
Primary Physician Email
*
example@example.com
Previous Employment
Job Title
*
Previous Employer(s)
*
Department/ Company
*
EIN
*
Current Condition
Please check the ones that you currently have.
*
Excessive Weight Loss/Gain
Impairment of hearing
Swelling
Nausea
Headaches
Fevers
Impairment of vision
Coughing
Fatigue
Dizziness
Numbness
Back/Chest Pain
Medical Information
Habits
*
Rows
Frequently
Neutral
Never
Exercise Frequency
1
2
3
Smoking Frequency
4
5
6
Drug Frequency
7
8
9
Drinking Frequency
10
11
12
Fast Food Frequency
13
14
15
Allergy Frequency
16
17
18
Describe your exercise type(s), previous medical conditions, surgeries, injuries, diagnoses. You also add anything else that you think it is medically important.
*
Last Date Treated
*
-
Month
-
Day
Year
Date
Vaccinations
*
Rows
Yes
No
Regular Childhood Vaccinations
19
20
Hepatitis A
21
22
Hepatitis B
23
24
Tuberculosis
25
26
Flu
27
28
Chicken Pox (illness is also acceptable)
29
30
Covid 19 (illness is also acceptable)
31
32
How many doses of Covid 19 vaccination did you get?
*
Professional Medical Requirements
If you require a medical device, please specify them. (e.g. face mask)
*
How many pounds do you think you can be able to lift during a day?
*
Will you be exposed with human bodily fluids (such as blood), dangerous or radioactive chemicals, or will you work with heavy machine(s)? Please specify them.
*
Signature
*
Date of Signed
*
-
Month
-
Day
Year
Date
Submit
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