Military Physical Examination Form
Complete this form for a military physical examination, fitness screening, or readiness evaluation. Provide accurate medical and physical information so the examiner can assess your suitability and any needed follow-up.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Sex/Gender
*
Please Select
Male
Female
Non-binary
Prefer to self-describe
Prefer not to say
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Branch/Service Category
Please Select
Army
Navy
Air Force
Marines
Coast Guard
Space Force
Other
Examination Details
Examination Date
*
-
Month
-
Day
Year
Date
Appointment / Visit Time
Examination Location / Unit
*
Examiner Name
*
First Name
Middle Name
Last Name
Purpose of Examination
*
Please Select
Enlistment
Periodic Fitness Check
Return-to-Duty
Medical Clearance
Other
Medical History
Any prior major illnesses?
*
No
Yes
If yes, provide details of prior major illnesses
Any prior surgeries or hospitalizations?
*
No
Yes
If yes, provide details of surgeries or hospitalizations
Are you currently taking any medications?
*
No
Yes
If yes, list current medications and doses
Do you have any allergies?
*
No
Yes
If yes, list allergies and reactions
Have you ever fainted or had seizures?
*
No
Yes
If yes, provide details of fainting or seizures
Do you have any other medical conditions relevant to this examination?
No
Yes
If yes, describe any other medical conditions
Physical Examination Measurements
Height (cm)
*
Weight (kg)
*
BMI
Blood Pressure (mmHg)
*
Pulse / Heart Rate (bpm)
*
Respiratory Rate (breaths/min)
*
Vision Screening Results
*
Hearing Screening Results
*
Fitness and Duty Readiness
Running Endurance
*
Meets requirements
Needs follow-up
Temporarily unfit
Conditionally fit
Not assessed
Lifting Capability
*
Meets requirements
Needs follow-up
Temporarily unfit
Conditionally fit
Not assessed
Cardiovascular Endurance
*
Meets requirements
Needs follow-up
Temporarily unfit
Conditionally fit
Not assessed
Mobility
*
Meets requirements
Needs follow-up
Temporarily unfit
Conditionally fit
Not assessed
Range of Motion
*
Meets requirements
Needs follow-up
Temporarily unfit
Conditionally fit
Not assessed
Posture
*
Meets requirements
Needs follow-up
Temporarily unfit
Conditionally fit
Not assessed
Balance and Coordination
*
Meets requirements
Needs follow-up
Temporarily unfit
Conditionally fit
Not assessed
Physical Limitations or Restrictions
None
Temporary activity restriction
Lifting restriction
Running restriction
Standing restriction
Sitting restriction
Requires follow-up evaluation
Other
Examiner Findings and Recommendation
Overall Examiner Notes
*
Fitness Status
*
Fit for Duty
Fit with Restrictions
Unfit for Duty
Recommended Follow-Up Tests or Referrals
Temporary Restrictions
Examiner Signature
*
Submit Examination
Submit Examination
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