Form Wmc-013 - University Of Florida Preplacement Physical Exam Wmc-013

ADVERTISEMENT

UNIVERSITY OF FLORIDA PREPLACEMENT PHYSICAL EXAM
POSITION #_________________
NAME: _____________________________________ UF ID: _______________ POSITION: _________________________
HEIGHT: ________ WEIGHT: _______ T: ________ PULSE: ________ RESP: ________ BLOOD PRESSURE: ________
VISION: ____________________ /____________________ Other: ______________________________________________
uncorrected
corrected
 AC  Asbestos  BBP  Diving  Generic  Hearing Cons  Pesticides  Police  Respirator  N-95
 Patient Contact  Other _______________________________________________________________________
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXdXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
OBSERVATIONS:
General Appearance
NL___ ABNL___
Neuro
NL___ ABNL___
Skin/Scars
NL___ ABNL___
Neck
NL___ ABNL___
Eyes
NL___ ABNL___
Upper Extremities
NL___ ABNL___
Thyroid
NL___ ABNL___
Back
NL___ ABNL___
Chest/Lungs
NL___ ABNL___
Lower Extremities
NL___ ABNL___
Heart/Vessels
NL___ ABNL___
Abdomen/Hernia
NL___ ABNL___
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXdXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
COMMENTS: __________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXdXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
IMMUNIZATIONS:
Tdap: ______ MMR: ______ ______ Chicken Pox: _____ _____ Hep B: _____ _____ _____ Rabies: _____ _____ _____
Other: ________________________________________________________________________________________________
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXdXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
OTHER TESTS:
PPD: _______ CXR: ________ PFT: _______ EKG: _______ CBC: ________ UA: ________ Chem Profile: ________
Serum Banking: ________ Varicella Titer: ________ Audiometry: ________ Cholinesterase Baseline: ________ ________
Other: ________________________________________________________________________________________________
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXdXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
RECOMMENDATIONS:
 No job-specific limitations
 Job-specific limitations: ________________________________________________________________________________
_____________________________________________________________________________________________________
I have been advised of the results of the medical examination I have just undergone. I understand that should I have medical
limitations specific to the job I have been offered, I must advise my employer of such limitations PRIOR to starting work.
______________________________________ ________________
Employee Signature
Date
____________________________________________
______________________________________ ________________
Examiner (MD, PA, ARNP) Printed Name
Examiner Signature
Date
WMC-013: Reviewed/revised 2012-10

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form W-9 - Taxpayer Identification Number Request - University Of Florida Form W-9 - Taxpayer Identification Number Request - University Of Florida Financial
University Of Florida - Vendor Tax Information Form - 2016 University Of Florida - Vendor Tax Information Form - 2016 Business
Form Dr-95b - Schedule Of Florida Sales Or Use Tax Credits Claimed On Repossessed Motor Vehicles Form - State Of Florida Form Dr-95b - Schedule Of Florida Sales Or Use Tax Credits Claimed On Repossessed Motor Vehicles Form - State Of Florida Financial
Form Dr-95a - Schedule Of Florida Sales Or Use Tax Credits Claimed On Tangible Personal Property Repossessed - Florida Department Of Revenue Form Dr-95a - Schedule Of Florida Sales Or Use Tax Credits Claimed On Tangible Personal Property Repossessed - Florida Department Of Revenue Financial
Form Dr-95a - Schedule Of Florida Sales Or Use Tax Credits Claimed On Tangible Personal Property Repossessed Form Dr-95a - Schedule Of Florida Sales Or Use Tax Credits Claimed On Tangible Personal Property Repossessed Financial
Form Dr-95b - Schedule Of Florida Sales Or Use Tax Credits Claimed On Repossessed Motor Vehicles Form Dr-95b - Schedule Of Florida Sales Or Use Tax Credits Claimed On Repossessed Motor Vehicles Financial
Form E911-ppws - Schedule Of Florida Prepaid Wireless E911 Fee By County Form E911-ppws - Schedule Of Florida Prepaid Wireless E911 Fee By County Financial
Graduate Student Registration Form - Department Of Psychology, University Of Florida Graduate Student Registration Form - Department Of Psychology, University Of Florida Life
Consent Form For Boy Scouts And Venture Group Physical Exam Consent Form For Boy Scouts And Venture Group Physical Exam Business
Photo Release Form - University Of Florida Photo Release Form - University Of Florida Legal

Related Categories

Parent category: Medical
Download
Go
Page of 2