Physical Examination Form

Every new provider completes a pre-employment physical examination before their first day. The exam is performed by a licensed physician of the applicant’s choice, who attests that the applicant is in good general health, free from communicable diseases, and physically and mentally capable of performing the duties of the position.

The Physical Examination Form on the right captures the applicant’s identifying information, vital signs and measurements, relevant medical history, the physician’s clinical evaluation, results of any tests performed (including PPD and chest x-ray when indicated), and the physician’s certification with any work restrictions. The bottom of the form captures the physician’s name, signature, medical license number, and date.

The applicant brings a blank copy of this form to their exam, the physician completes and signs it, and the completed form is returned to HR for the applicant’s file.