Pre-Employment Physical Exam Questionnaire
Full Name
Date of Birth
Position Applied For
Contact Information
Phone
Email
Medical History
Are you currently taking any medications?
Yes
No
If yes, please specify
Do you have any allergies?
Yes
No
If yes, please specify
Have you had any surgeries or hospitalizations?
Yes
No
If yes, please specify
Do you have any physical limitations or conditions that may affect your work?
Height
Weight
Additional Comments