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Blank Employee Physical PDF Form

The Employee Physical Examination Form is a critical document used to assess the health status of employees before they begin work. This form collects essential medical history and physical examination results to ensure that individuals are fit for their job responsibilities. Completing this form accurately is vital, so please fill it out by clicking the button below.

Article Guide

The Employee Physical Examination Form serves as a crucial document in the hiring process, ensuring that potential employees are fit for the demands of their roles. This form collects essential information about an individual's medical history, including previous conditions such as arthritis, asthma, and heart disease, which may impact their ability to perform specific job functions. It also requires candidates to disclose any current or past health issues, with a clear emphasis on honesty, as any misrepresentation could lead to termination. The form includes sections for vital statistics like height, weight, and vital signs, as well as assessments of vision and hearing capabilities. Furthermore, a thorough physical examination is documented, covering various systems of the body, from general appearance to neurological health. Physicians reviewing the form must evaluate the applicant's medical history and conduct tests for tuberculosis, ensuring a comprehensive understanding of the candidate's health status. Ultimately, the form not only safeguards the health of the workforce but also protects the organization from potential liability issues related to employee health and safety.

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P 908 312 1423 - www.fivestar.care - F 908 325 1975 216 River Avenue Suite 207 Lakewood, NJ 08701

EMPLOYEE PHYSICAL EXAMINATION FORM

PAGE 1

Last Name:

First Name:

Middle Initial: Today’s Date:

MEDICAL HISTORY: Do you now have, or have you ever had, any of the following:

		YES	NO			YES	NO
1.	Arthritis / Rheumatism			10.	Hepatitis A; B; C; other Infections
2.	Asthma / Wheezing			11.	Hernia(s)
3.	Back Injury/ Chronic Back Pain			12.	Hypertension /High Blood Pressure
4.	Broken Bones / Fractures			13. Jaundice / Liver Disease
5.	Cancer			14.	Sinus Trouble / Allergies
6.	Diabetes			15.	Skin Disease
7.	Emphysema / Lung Disease			16.	Stomach Trouble / GI Problems
8.	Head Injury / Unconsciousness			17.	Substance Abuse (History of Drug
					or Alcohol Abuse Problems)
9.	Heart Disease / Heart Attack			18.	Tuberculosis or History of Positive
					TB Skin Test

I have read the above and declare that I have no injury, illness or ailment other than is specifically noted above. Any falsification or misrepresentation will be sufficient grounds for my release from employment.

Employee’s Signature

Date

Any “YES” answer(s), please explain below.

Put the number (1, 2, 3, etc.) of the YES answer before the explanation:

( Example: “#12. I have been taking medication for high blood pressure since 2007.”)

P 908 312 1423 - www.fivestar.care - F 908 325 1975 216 River Avenue Suite 207 Lakewood, NJ 08701

EMPLOYEE PHYSICAL EXAMINATION FORM

PAGE 2

Last Name:

First Name:

Middle Initial:

Today’s Date:

Job Title:

DOB

Age

Sex

Temp.

Pulse

Resp.

B/P

Drug/Food Allergies

Vision: R 20/

L 20/

Pupils: Equal

Unequal Glasses/Lenses: Y / N

Hearing:  Normal  Impaired  Hearing Aid

PHYSICAL EXAM

NORMAL

ABNORMAL

COMMENTS

General Appearance / BMI

Skin

HEENT

Teeth

Neck

Lungs

Heart

Abdomen

GU System

10. Musculoskeletal Functioning

(Full ROM to all extremities? History

of injury to knees or hips?)

11. Back / Spine (History of injury?)

12. Neurological (Gross observation

of gait, coordination, tremors, etc.)

13. Psychiatric (tics, stuttering, nail-

biting, cognition, orientation, affect,

obvious personality disorders, etc.)

Physician’s review of person’s medical history as recorded on reverse side of this form:

PPD / Mantoux Test for Tuberculosis: 1st Step Date:

_ Result:

_ 2nd Step Date:

Result:

Chest X-Ray: Date Performed:

Results:

THIS APPLICANT IS FIT FOR EMPLOYMENT: YES:

NO:

Deferred for Functional Capacity Evaluation:


	Examining Physician’s Signature		Date Physical Examination Performed

➤ PDF File

Form Specifications

Fact Name	Description
Purpose of the Form	The Employee Physical Examination Form is designed to assess the medical fitness of an employee before they begin work.
Medical History	The form requires employees to disclose any past or present medical conditions, including serious illnesses and chronic conditions.
Falsification Consequences	Employees must acknowledge that any false information provided may lead to termination of employment.
State-Specific Requirements	In New Jersey, the form must comply with state laws regarding employee health assessments, including regulations under the New Jersey Administrative Code.
Physician's Review	A physician must review the medical history and perform a physical examination, documenting their findings on the form.
Allergy Information	Employees are required to list any drug or food allergies, which is crucial for their safety in the workplace.
Fit for Employment	The examining physician must indicate whether the applicant is fit for employment based on the examination results.

Employee Physical: Usage Guidelines

Completing the Employee Physical form is an essential step in the hiring process. This form gathers important information about your medical history and current health status. After filling out the form, it will be reviewed by a physician who will assess your fitness for employment.

Begin by entering your Last Name, First Name, and Middle Initial at the top of the form.
Write today’s date in the designated area.
In the Medical History section, carefully read each condition listed. Indicate whether you have had any of the conditions by marking YES or NO for each item.
If you answered YES to any condition, provide an explanation in the space provided. Use the corresponding number from the list to reference your explanation.
Sign and date the form at the bottom of the first page, confirming the accuracy of your information.
On the second page, fill in your Job Title, Date of Birth, Age, and Sex.
Record your Height, Weight, Temperature, Pulse, Respiration, and Blood Pressure in the appropriate fields.
List any known Drug/Food Allergies you may have.
Indicate your vision and hearing status, including whether you wear glasses or use hearing aids.
For each physical examination item, mark whether it is NORMAL or ABNORMAL and provide comments if necessary.
Complete the PPD / Mantoux Test and Chest X-Ray sections with the relevant dates and results.
Finally, the examining physician will sign and date the form, confirming the physical examination has been performed.

Your Questions, Answered

What is the purpose of the Employee Physical form?

The Employee Physical form is designed to assess the overall health and medical history of an employee. This information helps employers ensure that employees are fit for their specific job roles and can safely perform their duties. By collecting relevant medical history, the form aims to identify any potential health risks that may affect job performance or safety.

What should I include in the medical history section?

In the medical history section, you should answer questions regarding any past or present health conditions. This includes serious issues such as heart disease, diabetes, or asthma, as well as other conditions like allergies or chronic pain. If you answer "YES" to any of the questions, it is important to provide additional details. This helps your employer understand your health better and make informed decisions regarding your work environment.

What happens if I provide false information on the form?

Providing false information on the Employee Physical form can have serious consequences. If discrepancies are found, it may lead to your release from employment. Honesty is crucial. Employers rely on accurate information to maintain a safe and healthy workplace for all employees.

Who reviews the Employee Physical form?

The form is typically reviewed by a qualified healthcare professional, such as a physician or a nurse. They will evaluate your medical history and the results of your physical examination. Their assessment helps determine if you are fit for employment and if any accommodations are necessary for your health and safety.

What should I do if I have a medical condition that may affect my job?

If you have a medical condition that could impact your job performance, it’s important to disclose this information on the form. You should also discuss it with your employer or HR department. They can provide guidance on any necessary accommodations or support that may be available to help you perform your duties effectively.

How often do I need to complete the Employee Physical form?

The frequency of completing the Employee Physical form can vary by employer and job type. Some employers may require a new form annually, while others may ask for it only when there is a change in your health status or job role. Always check with your HR department for specific requirements related to your position.

Common mistakes

Failing to provide complete personal information, such as last name, first name, and date of birth, can lead to processing delays.
Not answering the medical history questions accurately may result in serious consequences. Each YES or NO must be marked correctly.
Neglecting to explain any YES answers can create misunderstandings regarding your health status.
Overlooking the section for drug and food allergies can pose risks during employment, especially in specific job environments.
Forgetting to sign and date the form invalidates the submission. A signature confirms the accuracy of the provided information.
Leaving out details about physical examination results can lead to incomplete assessments by the examining physician.
Failing to report any previous injuries or chronic conditions can impact your job performance and safety.
Not keeping a copy of the completed form for your records can hinder future reference or necessary follow-ups.

Documents used along the form

In addition to the Employee Physical form, several other documents are commonly used in the hiring and onboarding process. Each of these documents serves a unique purpose and contributes to ensuring a safe and compliant work environment.

Job Application Form: This document collects essential information about the applicant's qualifications, work history, and references. It helps employers assess candidates' suitability for the position.
Background Check Authorization: This form allows employers to conduct a background check on the applicant. It typically includes consent for checking criminal history, credit reports, and employment verification.
I-9 Employment Eligibility Verification: Required by federal law, this form verifies the identity and employment authorization of individuals hired for employment in the United States. It must be completed within three days of the employee’s start date.
W-4 Employee’s Withholding Certificate: This document is used by employers to determine the amount of federal income tax to withhold from an employee's paycheck. Employees provide information about their filing status and any additional withholding allowances.
Employee Handbook Acknowledgment: This form confirms that the employee has received and understood the company's policies and procedures outlined in the employee handbook. It serves as a reference for workplace expectations and guidelines.
Drug and Alcohol Policy Acknowledgment: This document outlines the company's stance on drug and alcohol use in the workplace. Employees must acknowledge their understanding of the policy and agree to comply with it.

These documents collectively ensure that both the employer and employee are aligned on expectations, legal requirements, and workplace standards. Proper completion and management of these forms can help facilitate a smooth onboarding experience.

Similar forms

Pre-Employment Medical Questionnaire: Similar to the Employee Physical form, this document collects health history and medical conditions that may affect job performance. It often includes questions about allergies, chronic illnesses, and previous surgeries.
Return-to-Work Form: This document assesses an employee's fitness to return after an illness or injury. Like the Employee Physical form, it requires medical history and a physician's evaluation to ensure the employee can safely resume their duties.
Occupational Health Assessment: This assessment focuses on health risks associated with specific job tasks. It shares similarities with the Employee Physical form in evaluating physical and mental health, ensuring that employees can perform their roles without risk to themselves or others.
Fitness for Duty Evaluation: Conducted to determine if an employee is capable of performing their job responsibilities. This evaluation includes a review of medical history and physical examination results, paralleling the thoroughness found in the Employee Physical form.
Health and Safety Compliance Form: This document ensures that employees meet health and safety regulations. It often requires information about medical conditions and fitness levels, much like the Employee Physical form, to maintain a safe workplace environment.

Dos and Don'ts

When filling out the Employee Physical form, it’s essential to provide accurate and complete information. Here’s a list of things to keep in mind, both what to do and what to avoid.

Do be honest about your medical history. If you have any conditions, it’s crucial to disclose them.
Do read the entire form carefully before starting. Understanding what’s required can help you avoid mistakes.
Do provide clear explanations for any “YES” answers. This helps medical professionals assess your health accurately.
Do ensure your contact information is correct. This allows for easy communication regarding your health assessment.
Don’t rush through the form. Take your time to think about your answers; this is important for your health and employment.
Don’t leave any sections blank unless instructed. Incomplete forms can lead to delays or complications in your employment process.
Don’t exaggerate or downplay your health issues. Providing truthful information is vital for your safety and well-being at work.

Misconceptions

Understanding the Employee Physical Examination Form is crucial for both employers and employees. However, several misconceptions often cloud its purpose and implications. Below are seven common misconceptions, along with clarifications.

It is only a formality. Many believe that the physical examination is merely a bureaucratic step. In reality, it serves to ensure that employees are fit for their roles, safeguarding both their health and workplace safety.
All medical conditions must be disclosed. Some individuals think they need to report every minor ailment. However, the form specifically asks for significant health issues that may affect job performance or safety.
Only physical health is evaluated. A common misconception is that the examination focuses solely on physical health. In fact, mental health assessments are also part of the evaluation, recognizing the importance of overall well-being.
Falsification leads to immediate termination. While misrepresentation can result in job loss, it is not always immediate. Employers may first investigate the circumstances before making a decision.
It is the same for all job positions. Many assume that the form is uniform across different roles. In truth, the requirements may vary based on the physical demands of specific jobs.
Results are shared with everyone. Some fear that their personal health information will be disclosed to colleagues. In reality, confidentiality is maintained, and results are typically shared only with relevant personnel.
It is optional to fill out. Some individuals think they can skip the form. However, completing the Employee Physical Examination Form is often a requirement for employment, particularly in safety-sensitive positions.

Addressing these misconceptions can lead to a clearer understanding of the Employee Physical Examination Form and its significance in the workplace.

Key takeaways

When filling out and using the Employee Physical Examination Form, consider these key takeaways:

Accuracy is Crucial: Ensure all information is filled out truthfully. Any inaccuracies can lead to serious consequences, including termination of employment.
Complete Medical History: Take time to carefully review and disclose any past or present medical conditions. This helps employers understand your health needs and can affect job placement.
Follow-Up on "YES" Answers: If you answer "YES" to any health questions, provide detailed explanations. This information is important for your medical evaluation and future health considerations.
Consult Your Physician: Before submitting the form, consider discussing it with your healthcare provider. They can help clarify any medical history and ensure you are fit for the job requirements.