Pre-Employment History And Physical Form
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4Pre-Employment History and Physical Form
Personal Data
Name (Last, First, MI):
SSN:
:
/
/
Date of Birth
Age:
Ethnicity:
Phone Numbers:
Home (
)
-
Mobile (
)
-
Work (
)
-
Address:
(street)
(city)
(state)
(zip)
Job Title & Department:
Union:
If yes, specify:
Yes
No
Current Medical Provider
Name of doctor:
Phone Number: (
)
-
Address:
(street)
(city)
(state)
(zip)
Prior Employment
Start with most recent job
Job Title
Employer/City/State
Dates of employment (mo/yr)
1
/
/
to
2
/
/
to
3
/
/
to
4
/
/
to
Review of Symptoms
Do you have any of the following?:
Do you have any of the following?:
Yes No
Yes No
Weight loss / Weight gain (circle)
Palpitations or skipped beats
Fevers
Chest pain or tightness
Headaches
Indigestion/heartburn
Difficulty with vision / Wear lenses or glasses
Abdominal pain
Dizziness / Vertigo
Diarrhea/constipation
Difficulty hearing
Irregular periods
Seasonal allergies
Frequent urinary tract infections
Sinus problems
Kidney stones
Tiredness or falling asleep during the day
Back pain
Unable to tolerate heat or cold
Joint pain or swelling
Shortness of breath with or without exertion
A history of broken bones
Wheezing
Swelling of the legs
Cough
Skin problems (rash, eczema, psoriasis)
Vaccination History/Communicable Diseases
Have you had:
Yes
No
Unsure
The standard series of childhood vaccinations (to the best of your knowledge)?
The disease “chicken pox” or the chicken pox vaccine (varicella)?
A tetanus/diphtheria booster shot within the last 10 years?
Hepatitis B vaccination (this is a series of three injections spaced several months apart)?
The disease “Tuberculosis”?
A positive tuberculosis test (also called a PPD or Tine test)?
Vaccination against tuberculosis with BCG (this is uncommon in the United States)?
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Parent category: Medical