Post on 16-Jul-2020
Patient Information
Name: _____________________________________ Birth date ______________ Soc. Sec #_____________________
Address: _________________________________________________________________________________________
__________________________________________________________________________________________________
Home phone: ______________________________________ Cell Phone:____________________________________
Employer (Name, Address)________________________________________________________________________
_________________________________________________________________________________________________
Examination Consent
_______________________________ has requested that we evaluate your ability to perform your job safely. This involves obtaining a general medical history and a physical examination including tasks such as lifting or pushing. Occasionally, additional testing or consultation with a specialist or the employer may be required to determine your ability to perform the tasks of the job. Be advised that this visit is for an evaluation only and not for treatment. After the evaluation, you will be notified of any identified problems that may require further medical care. You are responsible for arranging this with your own provider.
For post-offer job placement assessments, we will send the employer a written opinion. This report is simply our opinion of your ability to safely perform the essential functions of your job. It will indicate whether you need accommodations or special job training in order to do this job. No medical information will be provided in that report unless you provide us with a written release to do so.
For DOT examinations, a medical certificate, which complies with the requirements set forth in the Federal Motor Carrier Safety Regulations (49CFR) will be provided to the company. Some employers require the long DOT medical form, which contains your medical history and examination findings, be returned to them. (this is allowed by the regulations).
Certain companies require the applicant/employee to complete special medical forms and return them to the company or another identified representative (e.g. their medical department). By signing below you are agreeing to allow us to do this. With all other companies, your medical information will not be released to your company without your written consent.
By signing below, you are indicating that you understand the above information and consent to the medical examination and release of appropriate information to your employer/prospective employer.
Signature: ________________________________________ Date: __________________
Witness: __________________________________________ Date: __________________
Medical History
For Post-Offer and Medical Surveillance Examinations
Name: First Middle Last Date of Birth: Company:
The following questionnaire will be used to determine the condition of your health. For job placement assessment candidates, this will be used to establish your baseline health status and determine appropriate job accommodations and assignments. For workers undergoing medical surveillance, it will allow the physician to identify whether any early or adverse health effects due to hazardous work exposures have developed so that appropriate treatment and/or safety recommendations can be made to you and your employer.
It is important that you be as complete as possible. Failure to provide important information regarding your health history with this examination may adversely affect your employment with this company.
Have you had or do you now Have: Yes No Have you had or do you now Have: Yes No
Ear, Nose, throat or sinus trouble Hay fever, hives or other allergies
Broken eardrum Latex or other substance related allergy
Eye trouble, eye injury or disease Multiple chemical sensitivity
Color blindness Bronchitis/pneumonia
Worn glasses Lung disease or emphysema
Trouble with mouth, gums or teeth Tuberculosis or a positive TB skin test
Difficulty swallowing Pleurisy or fluid in lungs
Hoarseness Frequent or persistent cough
Loss of sense of smell Coughing up blood
Ringing in ears Shortness of breath
Difficulty with hearing Stomach or intestinal problems
Heart trouble Ulcers/gastritis or GE reflux
High blood pressure Liver trouble, Hepatitis, or jaundice
Stroke Gall bladder trouble
Heart murmur Hemorrhoids
Heart attack, “MI” If yes, when?
Abdominal pain
High cholesterol Bowel trouble or change in bowl habits
Varicose veins Chronic nausea or vomiting
Phlebitis or blood clots Blood in bowel movements
Problems with circulation Persistent diarrhea or constipation
Chest Pain/angina Kidney, bladder or urinary problems
Leg pain with exertion/exercise Blood in urine
Cardiac stress test (treadmill test to check for heart disease), EKG, or other heart tests
Reproductive organ problems
Rapid heart beat Motor vehicle accident related injury
Asthma or wheezing Other significant trauma
Hernia Do you have any current work restrictions?
Illness due to indoor air pollution (e.g. mold, ventilation problems, dust, chemicals, etc.) If yes, list your symptoms:
Previous work injuries: Injury Company
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Have you had or do you now have? Yes No Have you had or do you now have? Yes No
Broken or fractured bones Frequent headaches or migraines
Dislocated or injured joints Cancer, cyst, growth or tumor
Back or neck herniated disc or surgery Sleep disturbance
Back trouble or back injury Fainting or dizzy spells
Recurrent or chronic back pain Tremors
Sciatica Balance or coordination problems
Arthritis, rheumatism, bursitis or gout Convulsions, fits or seizures
Fibromyalgia Numbness, tingling, or weakness
Tendinitis Anemia, blood problems or blood disease
Tennis elbow, golfers elbow, epicondylitis Bleeding tendency
Carpal tunnel syndrome Night sweats
Hand numbness or tingling Unexplained fever
Neck injury or whiplash Gland disorders
Injury to pelvis, hips, knees, ankles, feet Diabetes
Injury to the shoulders, arms hands Thyroid disease
Chronic muscle or joint pain. If yes, where?
Persistent fatigue
Other muscle or bone injury or conditions Increased thirst, hunger or urination
Nervous or mental problems Chronic infection, immune system disorder
Depression or anxiety Recent weight gain (> 10 lbs in past year)
Claustrophobia (fear of closed in spaces) Recent weight loss (> 10 lbs in past year)
Head injury or concussion Skin trouble, dermatitis or eczema
Loss of consciousness Alcohol or drug problems
Comments:
Medications: Prescription _______________________________________________________________________________________ Medical Marijuana Card______________________________________________________________________________ Over the counter, Herbal Remedies and Vitamins__________________________________________________________ How much caffeinated coffee/tea/cola/chocolate do you drink a day? ________________________________________ Medication/Food/Allergies____________________________________________________________________________ Vaccinations (reactions)______________________________________________________________________________ Immunizations: When was your last Tetanus Shot? ________ Unknown Have you ever had Hepatitis B Vaccination? Yes No If yes, did you complete the series B shots? Yes No Operations and hospitalizations, please list all including year: ________________________________________________ __________________________________________________________________________________________________
TOBACCO USE ALCOHOL USE
Please check off and answer all that apply to you: Please check off and answer all that apply to you:
Never smoked Former smoker
How often do you drink alcohol?
Quite smoking when?
Smoked how many years? When you drink, how many drinks, on average, do you have?
Approx. how many packs per day?
Current smoker
Age started smoking Have you ever been a problem drinker or treated for alcohol
Smoke how may packs per day? Overuse Yes No
Use other tobacco products
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Exercise: do you exercise on a regular basis? Yes No IF YES, how often and what type of exercise? ______________________ Family Medical History: (place an X in the appropriate box and the age when the condition developed)
Health condition Parent Grandparent Brother/Sister/Child Heart attack, MI, angina, Heart problems, bypass surgery
High cholesterol High blood pressure, hypertension Lung or breathing disease Cancer Other serious disease, conditions Occupational History:
Job Title Company Most recent job:
Previous job: Previous job: Previous job: Work Hazard and Environmental Exposure History: Please check off all categories of hazards/chemicals to which you have been exposed at work, home or with hobbies/recreation. Exposure Yes No Unknown Exposure Yes No Unknown Radiation Insecticides, herbicides, pesticides Contaminated water sources Noise Biological agents (animals, bacteria, viruses, molds, tuberculosis, etc.)
Solvents (e.g. benzene, carbon tetrachloride, glycol, ethers, ketones, carbon disulfide)
Petroleum based chemicals (e.g. asphalt and tar, coal tar, naphthalene, PCP’s, PBBs PAHs, petroleum distillates)
Plastics (e.g. vinyl, chloride, epoxy resins, styrene, acrylonitrile, fluorocarbons)
Blood born pathogens Have you ever had an exposure to blood or other potentially infectious materials (e.g. a needlestick, splash of blood to the eye)
Other Chemicals:
Metal, metal fumes (e.g. lead, arsenic, mercury, nickel other)
Inorganic dusts or powders (e.g. asbestos, fiberglass, silica coal, etc)
Chemotherapeutic agents (e.g. cancer drugs) Heavy physical labor, repetitive tasks, vibration
Tobacco Smoke – work or home Other hazards
Have you had any unexpectedly high exposures to hazards at the workplace recently or in the past? Yes No Did you become ill with these exposures? Yes No Do you have any known condition that prevents you from working nights or shift work? Yes No I certify I have completed my health history honestly and completely to the best of my knowledge. ___________________________________________________ ________________________________ Signature Date
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Patient NAME:___________________________________________ DOB:____________________
Clinician Examination VITAL SIGNS: BP_________________ Pulse _______ Respiration__________ Height_________ Weight___________________BMI__________
URINE DIP: Blood _____________ Protein _____________ Specific Gravity ________ Glucose _________ PH _______ Other__________
Vision: Contacts: Yes No Glasses: Yes No Glasses/contacts not available at the time of exam: Yes No Medical assistant: For eyeglass/contact wearers, perform test only with correction, unless the devices are unavailable. Near Vision Far Vision Satisfactory Unsatisfactory Corrected Uncorrected Corrected Uncorrected Fusion__________ __________________ Right 20/_____ 20/______ 20/______ 20/___________ Depth___________ __________________ Left 20/_____ 20/______ 20/______ 20/___________ Color____________ __________________ Both 20/_____ 20/______ 20/______ 20/___________ Peripheral ________ __________________
(X) Normal Organ System (x) Abnormal NE if not examined
Clinical Findings
1.General – Nutrition/body habitus, affect/personality
2. Eyes – Sclera, conjunctiva, pupils 7 fundi, extra ocular muscles
3. Head/Face
4. Ears – Canals, TMs conversational hearing
5. Nose
6. Mouth/throat – Dentition, or pharynx
7. Neck – Carotids, thyroid, lymph nodes
8. Lungs/Thorax – Shape, motion, lungs sounds
9. Heart – Size, rhythm/murmur/click
10. Abdomen – Scars, organs, masses, hernia, sounds, bruits
11. Vascular system – Varicose veins, pulses, edema
12. Rectal/prostate
13. Neurologic – reflexes, CNS, gait, sensation, balance, CNS, strength
14. Skin/nails – Tattoos, birth marks
15. Musculoskeletal – Posture, upper extremities, lower extremity, spine
16. Special tests – Tinels, Phalens, Finkelstein, Hyperflexion test, etc.
17. Pinch Strength/Grip Strength
Comments: Provider Signature:_____________________________________________________________Date:________________________________________________________