Court Officer Physical Examination Form
Use this form to record a court officer’s physical examination, functional fitness, and any follow-up recommendations. Fill in the requested examination details accurately.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender Identity
Female
Male
Non-binary
Prefer not to say
Prefer to self-describe
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Employing Court/Department
*
Role/Position
*
Physical Examination Details
Exam Date
*
-
Month
-
Day
Year
Date
Examiner Name
*
Height (cm)
*
Weight (kg)
*
Blood Pressure
*
Heart Rate / Pulse (bpm)
*
Vision Screening - Left Eye
*
Vision Screening - Right Eye
*
Hearing Assessment
*
Please Select
Normal
Mildly Reduced
Needs Follow-Up
Respiratory Status
*
Please Select
Normal
Mildly Abnormal
Needs Follow-Up
Musculoskeletal / Strength / Mobility Notes
General Physical Findings
Functional Fitness and Duty Readiness
Ability to stand or walk for extended periods
*
Yes
No
Limited
Requires Accommodation
Ability to lift or carry moderate weight
*
Yes
No
Limited
Requires Accommodation
Ability to climb stairs or perform rapid movement if required
*
Yes
No
Limited
Requires Accommodation
Endurance or stamina concerns
*
None
Mild
Moderate
Significant
Restrictions or accommodations needed
Overall fitness for duty recommendation
*
Fit
Fit with Restrictions
Not Fit Pending Follow-Up
Medical History and Current Conditions
Current Medications
Known Allergies
Ongoing Medical Conditions or Recent Injuries
Prior Surgeries or Relevant Musculoskeletal Issues
Recent Symptoms During Exertion
Chest pain
Dizziness
Shortness of breath
Fainting
Palpitations
None reported
Other
Recommended Follow-Up Testing
Exam Notes and Follow-Up
Examiner comments
Additional observations
Recommended referral or follow-up
Final status / next steps
*
Cleared
Cleared with restrictions
Needs re-exam
Referred for specialist evaluation
Submit
Should be Empty: