"Medical Examination Form"

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MEDICAL EXAMINATION FORM
NAME: ________________________________________________ SEX: ____________ AGE: __________
COMPANY: _____________________________________________ CIVIL STATUS: __________________
CONTACT NO: ___________________________________________ NATURE OF WORK: ______________
COMPELETE ADDRESS:______________________________________________________________________
REQUESTED FOR: _____ Periodic Health Examination_____ Pre-Employment_____Medical Evaluation
I. PAST MEDICAL HISTORY
Childhood Illnesses: ___ Measles___Mumps___Rubella___Chicken Pox___ Rheumatic Fever____ Polio
Present Illnesses:
___ HTN___ DM___ Asthma___ PTB___ Goiter___ CA___ Allergies___ Others
Medical Illnesses taking maintenance medications:
______________________________________________________________________________________
_____________________________________________________________________________________________
Surgeries: ____________________________________________________________________________________
Hospitalizations: ______________________________________________________________________________
II. FAMILY HISTORY:
Yes
No
Remarks
Allergy:
______________________
Arthritis:
______________________
Bronchial Asthma:
______________________
Pulmonary Tuberculosis:
______________________
Hypertension:
______________________
Thyroid Disease:
______________________
Neurological Disorders:
______________________
Diabetes Mellitus:
______________________
Heart Disease:
______________________
Gastrointestinal Disease:
______________________
Kidney Disease:
______________________
Blood Disorder:
______________________
Psychiatric Illness:
______________________
Others:
______________________
III. PERSONAL & SOCIAL HISTORY
Yes
No
Remarks
Smoking History:
______________________
Alcohol Intake:
______________________
Allergies:
______________________
Drug Use:
______________________
For Women: G___P___(___-___-___-____)
LMP:______________
IV. REVIEW OF SYSTEMS
Yes
No
Remarks
Skin:
_____________________
HEENT:
_____________________
Chest/Breast:
_____________________
Heart/Lungs:
_____________________
Abdomen:
_____________________
Bladder:
_____________________
Bowel:
______________________
Extremities:
_______________________
Recent Changes in: _____Weight
_____ Energy Level
_____ Ability to sleep
Details:
_____________________________________________________________________
MEDICAL EXAMINATION FORM
NAME: ________________________________________________ SEX: ____________ AGE: __________
COMPANY: _____________________________________________ CIVIL STATUS: __________________
CONTACT NO: ___________________________________________ NATURE OF WORK: ______________
COMPELETE ADDRESS:______________________________________________________________________
REQUESTED FOR: _____ Periodic Health Examination_____ Pre-Employment_____Medical Evaluation
I. PAST MEDICAL HISTORY
Childhood Illnesses: ___ Measles___Mumps___Rubella___Chicken Pox___ Rheumatic Fever____ Polio
Present Illnesses:
___ HTN___ DM___ Asthma___ PTB___ Goiter___ CA___ Allergies___ Others
Medical Illnesses taking maintenance medications:
______________________________________________________________________________________
_____________________________________________________________________________________________
Surgeries: ____________________________________________________________________________________
Hospitalizations: ______________________________________________________________________________
II. FAMILY HISTORY:
Yes
No
Remarks
Allergy:
______________________
Arthritis:
______________________
Bronchial Asthma:
______________________
Pulmonary Tuberculosis:
______________________
Hypertension:
______________________
Thyroid Disease:
______________________
Neurological Disorders:
______________________
Diabetes Mellitus:
______________________
Heart Disease:
______________________
Gastrointestinal Disease:
______________________
Kidney Disease:
______________________
Blood Disorder:
______________________
Psychiatric Illness:
______________________
Others:
______________________
III. PERSONAL & SOCIAL HISTORY
Yes
No
Remarks
Smoking History:
______________________
Alcohol Intake:
______________________
Allergies:
______________________
Drug Use:
______________________
For Women: G___P___(___-___-___-____)
LMP:______________
IV. REVIEW OF SYSTEMS
Yes
No
Remarks
Skin:
_____________________
HEENT:
_____________________
Chest/Breast:
_____________________
Heart/Lungs:
_____________________
Abdomen:
_____________________
Bladder:
_____________________
Bowel:
______________________
Extremities:
_______________________
Recent Changes in: _____Weight
_____ Energy Level
_____ Ability to sleep
Details:
_____________________________________________________________________
V. PHYSICAL EXAMINATION:
General Appearance:
_______________
Temperature:
Height:
_______________
Weight:
_________
Body Mass Index:
______________
BP:
_______________
PR:
_________
RR:
______________
Visual Acuity:
_______________
OD
_________
OS
______________
With Objective Findings ?
Yes
No
Remarks
Head
_______________________
Eyes & Ears
_______________________
Nose & Sinuses
_______________________
Mouth
_______________________
Neck, Nodes & Thyroid
_______________________
Chest & Breast
_______________________
Heart & Lungs
_______________________
Abdomen
_______________________
Pelvic Exam
_______________________
Skin & Glands
_______________________
Extremities
_______________________
Neurological Exam
_______________________
VI. OTHER EXAMINATIONS
With Objective Findings?
Yes
No
Remarks
Chest X-ray
______________________
Urinalysis
______________________
CBC
______________________
ECG
______________________
Blood Chemistry
______________________
Fecalysis
______________________
VII. IMPRESSION:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
VIII. RECOMMENDATIONS
___________________________________________________________________________________________
___________________________________________________________________________________________
Pre-employment Classification:
_____A. Medically Fit for Employment
_____B. Medically Ft for Employment with Minimal Findings
_____C. With Obvious Defect but Maybe Employed at Management’s Discretion
_____D. Medically Unfit for Employment
_____E. With Pendings: ________________________________________________________________________
Medical Evaluation Decision:
_____For Completion of Medical Evaluation
_____Approved for Membership
_____Disapproved for Membership
_____To Sign Waiver for _______________________________________________________________________
Medical Examiner: ________________________________________
_______________________
License No:
________________________________________
Clinic Operations Manager
Date Examined:
_________________________________________
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