Medical Fitness Format for New Employee

PRE-EMPLOYMENT MEDICAL EXAMINATION


From To
The Human Resources Department Senior Medical Officer
Kindly examine Mr/ Mrs./Miss ……………………………………..who is being considered for our employment at our Life Spring Hospitals.

Date : Signature

PHYSICAL EXAMINATION

Height ……………… Weight : ………………..

Chest Expansion
Inspiration Expiration :

BLOOD PRESSURE :

Lying Standing :

Anemia Jaundice Lymphadenopathy Edema

SYSTEM EXAMINATION :
Respiration :

CVS :

CNS :

ABD :

PAST HISTORY : Asthma, Heart Disease , TB, Hepatitis, Chicken pox, Depression,
Major psychiatric disorder, Epilepsy, Drug and alcohol dependence,
Any other…etc.

Allergy : Any Medication Latex

PRESENT STATUS ON INVESTIGATIONS :

REMARKS : FIT/ UNFIT/ TEMPORARILY UNFIT.


SIGNATURE OF THE DOCTOR WITH DATE :


NAME OF THE DOCTOR ((in block letters)):

Thanks for input.we should also include the registration number of the certifying medical officer.