Form Wmc-013 - University Of Florida Preplacement Physical Exam Wmc-013 Page 2

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UNIVERSITY OF FLORIDA PREPLACEMENT PHYSICAL EXAM
MEDICAL HISTORY
NAME: _____________________________________________ UF ID: __________________________________________
Last
First
MI
ADDRESS: ____________________________________________________________________________________________
Street
City
State
Zip
PHONE: ____________________________________________ DATE OF BIRTH (MM/DD/YYYY): ____________________
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXdXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
As part of our effort to insure that your employment with the University does not worsen any pre-existing medical problem, we
ask that you answer the following questions.
This history and physical is not a substitute for a comprehensive examination by your personal physician and does not include
cancer screening, cholesterol testing, etc. Any of our findings will be shared with you and your physician upon request. We are
not authorized to treat conditions detected during this exam.
Indicate below if you have ever been treated for any of the following conditions:
YES NO
YES NO
Seizures
Anemia
Loss of Consciousness
Arthritis
Severe Headaches
Neck Injury
Heat Disorders
Shoulder Injury
Hay Fever/Allergies
Wrist Problem
Indoor Air Problems
Finger Injury
Thyroid Disease
Back Strain
Asthma
Herniated Disc
Pneumonia
Hip Problem
Tuberculosis (TB)
Knee Injury
High Blood Pressure
Ankle Injury
Heart Disease
Foot Problem
Ulcers
Emotional Disturbance
Liver Disease
Surgery
Kidney Stones
Work-Related Injury/Illness
Diabetes
Examiner Comments: ___________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Medication Allergies: ___________________________________________________________________________________
Current Medications (include supplements, over-the-counter medications, etc.): ________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Do you have any health conditions you think may hinder your performance on the job or may require your work to be modified?
 NO
 YES: _______________________________________________________________________________________
______________________________________ _________________________ ____________________________________
Employee Signature
Date
Reviewed By
WMC-013: Reviewed/revised 2012-10

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