Employee Physical Patient Information Marital status MS PHYSICAL EXAMINATION HEAD: CARDIOVASCULAR: EYES: MUSCULUOSKELETAL: NECK: ABDOMEN: BREASTS: GENITOURINARY: LUNGS: CENTRAL NERVOUS SYSTEM: COMMENTS: SEX MF HT: WT: B/P: PULSE: RESP: TEMP: LABORATORY TEST REULTS PPD #1 Date implemented Date read PPD #2 Date implemented Date read IF your patient has previously tested positive for tuberculosis either via a tuberculin skin test or a Quantiferon type blood test. A new chest x-ray IS required to rule out active tuberculosisA new chest x-ray is NOT required to rule out active tuberculosis TB GOLD QUANTIFERON CHEST X-RAY RUBELLA TITER - NEW HHA RUBEOLA TITER - NEW HHA RUBELLA (ONE DOSE REQUIRED) – NEW HHA RUBEOLA/MEASLES (TWO DOSES REQUIRED) - NEW HHA #1 #2 INFLUENZA Date EXP. DATE Tuberculosis (TB) Screen – Has patient had the following symptoms? CHEST PAIN YESNO WEIGHT LOSS YESNO LOSS OF ENERGY YESNO LINGERING COUGH YESNO BLOOD IN SPUTUM YESNO INCREASED SWEATING AT NIGHT YESNO CHAIN OF CUSTODY DRUG SCREEN This individual is free from any health impairment that is a potential risk to a patient or which might interfere with the performance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual’s behavior. This individual is able to work with the following limitations: This individual is not physically/mentally able to work: Physician Signature Sign x DATE Δ
