Pre Employment Physical Examination Form
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4Pre-Employment Physical Examination
These forms will be retained on the employee’s personal file.
Section 1 Physical Examination (to be completed by Medical Practitioner)
Name of applicant: _________________________________________________________________
Date completed: ___________________________________________________________________
Height: __________________________________________________________________________
Weight: __________________________________________________________________________
Ears
Left
Right
Wax
Yes
No
Yes
No
Otitis external
Yes
No
Yes
No
Otitis media
Yes
No
Yes
No
Perforation tympanic membrane
Yes
No
Yes
No
Scars tympanic membrane
Yes
No
Yes
No
Audiogram results:
_____________________________________________________________
Eyes
Distance vision
Right______
Left______
With glasses / contact lens
Right______
Left______
Skin
Any evidence of Eczema and/or Dermatitis
Yes
No
Cardiovascular
Normal heart sounds
Yes
No
Murmurs
Yes
No
Varicose veins
Yes
No
Angina
Yes
No
Heart failure
Yes
No
Absent peripheral pulses
Yes
No
Pulse Rate:
_____________________________________________________________
Blood Pressure:
_____________________________________________________________
Respiratory
Wheeze
Yes
No
Symmetrical chest expansion
Yes
No
Neck nodes
Yes
No
Crepitations
Yes
No
Rhonchi
Yes
No
Gastro Intestinal
Abnormality of:
Spleen
Yes
No
Liver
Yes
No
Kidney
Yes
No
Abdominal scars
Yes
No
Hernia
Yes
No
Urinalysis results:
_____________________________________________________________
Pre-Employment Physical Examination Form
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