Occupational Health Visit Report Form
Complete this report to document the details of an occupational health visit.
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Name
*
First Name
Last Name
Employee Department or Job Title
*
Employee ID (if applicable)
Reason for Visit
*
Please Select
Routine health check
Work-related injury
Work-related illness
Return to work assessment
Other
Presenting Symptoms or Complaint
*
Clinical Findings
*
Assessment / Diagnosis
*
Recommendations or Work Restrictions
Name of Health Professional Completing Report
*
First Name
Last Name
Submit Report
Should be Empty: