Employee Occupational Health Medical Form
Employee Information
Name
Employee ID
Department
Position/Title
Date of Birth
Medical Information
Relevant Medical History
Current Medications
Known Allergies
Immunization Status
Occupational Health Assessment
Workplace Exposure Risks
Personal Protective Equipment Needed
Fitness for Work
Fit for work
Fit with adjustments
Not fit for work
Recommended Adjustments
Healthcare Provider
Name of Healthcare Provider
Signature
Date