Pre-Employment Physical Examination Form
Personal Information
Full Name
Date of Birth
Sex
Male
Female
Other
Email
Phone
Position Applied For
Address
Medical History
Have you ever been hospitalized?
Yes
No
If yes, please specify
Current Medications
Allergies
Physical Examination
Height (cm)
Weight (kg)
Blood Pressure
Vision
Hearing
Physical Findings
Physician's Summary and Recommendation
Summary
Recommendation
Fit for Employment
Unfit for Employment
Physician Name
Date
Signature