Pre-Employment Physical Assessment
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Position Applied
Date of Assessment
Medical History
List any chronic illnesses, injuries, surgeries, or relevant medical history
Current Medications
Allergies
Physical Measurements
Height (cm)
Weight (kg)
Blood Pressure (mmHg)
Pulse (bpm)
Assessment Findings
Vision
Hearing
Musculoskeletal
Other Findings
Physician's Comments
Assessment Outcome
Fit for Duty
Fit
Fit with Restriction
Unfit
Restrictions or Recommendations
Physician Name
Signature
Date