ANNEX F

EMPLOYEE’S HISTORY AND PHYSICAL EXAM FORM

Personal Data
Name (Last, First, MI): Patient’s ID No.:

Date of Birth: (mm/dd/yyyy) Age: Sex: Contact No.: Nationality:

Address:

Position: Department:

Review of Symptoms

Have you ever had or do you have any of the Have you ever had or do you have any of the
Yes No Yes No
following conditions? following conditions?
Cough Abdominal pain

Difficulty with hearing Back pain

Difficulty with vision/ wear contact lenses or Chest pain or tightness
glasses
Dizziness/ Vertigo Diarrhea / Constipation
Fever Frequent Urinary Tract Infection (UTI)
Headache History of broken bones
Seasonal Allergies Indigestion / Heartburn
Shortness of breath with or without exertion Irregular periods
Sinus Problems Joint pain or swelling
Tiredness of falling asleep during the day Kidney stones
Unable to tolerate heat or cold Palpitations or skipped beats
Weight loss/ Weight gain Skin problems (rash, eczema, psoriasis)
Wheezing Swelling of legs

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 ten (10) years?
Hepatitis B vaccination (this is a series of three injections spaced several months apart)?
Tuberculosis
A positive tuberculosis test (also called a PPD test)?
Vaccination against tuberculosis with Baccillus Calmette-Guerin (BCG)?

Have you had:

 Car Accident  Loss of consciousness  Heart Attack  Abnormal heart rhythm
 Seizure  Panic Attacks  Head Injury  Stroke
 Paralysis  Back Injury  Psychiatric Disorder  Others

Current Medical Conditions

Those conditions that you are currently experiencing and/or receiving treatment for (such as diabetes, high blood pressure, migraine, etc.):
List Date of onset (month/year) List Date of onset (month/year)
1 / 3 /
2 / 4 /

Past Medical Conditions

Those conditions that you have in the past but have recovered from (such as childhood asthma, gestational diabetes, etc.):
List Date of onset (month/year) List Date of onset (month/year)
1 / 3 /
2 / 4 /
1
 ANNEX F
EMPLOYEE’S HISTORY AND PHYSICAL EXAM FORM

Surgeries/Hospitalization
List types of surgery (such as gall bladder) or condition for which you were hospitalized (such as heart attack, pneumonia, etc.):
List Date of onset (month/year) List Date of onset (month/year)
1 / 4 /
2 / 5 /
3 / 6 /

When was your last visit to the emergency room? _____________ For what symptom/condition? ___________________

Family History
Please list any conditions that run in your biological family (even if relative is deceased):
List Circle affected relatives List Circle affected relatives
1 Father/Mother/Sister/Brother/ 4 Father/Mother/Sister/Brother/
Child/Grandmother/Grandfather Child/Grandmother/Grandfather
2 Father/Mother/Sister/Brother/ 5 Father/Mother/Sister/Brother/
Child/Grandmother/Grandfather Child/Grandmother/Grandfather
3 Father/Mother/Sister/Brother/ 6 Father/Mother/Sister/Brother/
Child/Grandmother/Grandfather Child/Grandmother/Grandfather

Medications
Please include non-prescription medication, vitamins, and herbal supplements in addition to prescription medication:
1 4 7

2 5 8

3 6 9

Do you have allergies to medications or other substances? Yes No (If yes, please specify):

_________________________________________________________________________________________________
Social History

Do you smoke?  Yes  No  used to smoke, but quit If yes, how many cigarettes per day? _____ Per week? _____
How many alcoholic drinks do you consume per day? _____ Per week? ______ Do you use illicit/illegal drugs? Yes No
How many minutes of exercise do you get per day? ____________ How many days per week do you exercise? ___________
How many hours of television do you watch per day? ___________ How many times do you eat fast food per week? ___________

Occupational Assessment

Please answer the following questions regarding the job for which you have been hired: Yes No Unsure

Will you be required to wear respiratory protection (e.g. N95 mask cartridge respiratory)?
Do you anticipate working with hazardous chemicals or materials, infectious agents, or laboratory animals?
Is there a chance that you will be expose to human blood or body fluids as a result of routine job duties?
If your job involves working at computer, have you had or are experiencing any discomfort, pain, or numbness
when working at your desk?
Will you be required to drive a vehicle for any reason?
Will you be required to move heavy objects regularly (i.e., greater than (fifty) 50 pounds occasionally or
twenty-five (25) pounds frequently)?
Have you ever had an occupational injury/illness before (e.g., back strain, needle-stick, chemical exposure)?

Do you have any condition (physical, medical, or psychological) that would require special accommodation in order
for you to perform your job? Yes No If yes, please specify:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Signature of employee: __________________________________________________ Date: ___________________________

2
 ANNEX F
EMPLOYEE’S HISTORY AND PHYSICAL EXAM FORM

EMPLOYEE HEALTH PROFILE

(Immunization Record)

Employee Personal Data

Name :
Position Title :
ID No. :
Nationality :
Date of Birth :
Blood Group :

Pre-Employment Assessment (Confidential)

Viral Serology Screening Result Date
HIV
HBsAg
HCV Ab

HBV Vaccine
HBsAb Vaccinated Yes No Date
HB Titer
1st Dose
2nd Dose
3rd Dose

PPD/TST
Date Result CXR Result/ Comment

Vaccination History
Vaccine Yes No Date
Measles
Mumps
Chicken Pox

Other Vaccines
Vaccine Date Initial
Meningitis
Influenza
Polio
DPT

3
 ANNEX F
EMPLOYEE’S HISTORY AND PHYSICAL EXAM FORM

DIAGNOSTIC RESULTS

CBC

Urinalysis

Fecalysis

CXR

ECG Final Result

Blood Chem

HBsAg

HIV Screening

4
 ANNEX F
EMPLOYEE’S HISTORY AND PHYSICAL EXAM FORM

PHYSICAL EXAMINATION

Height Weight BMI Blood Pressure Pulse Respiration Temperature

Vision : Uncorrected/Corrected: OD-______/_____ OS-_____/______OU-_______/_______

HEENT : _________________________________________________________________________________________

Neck : _________________________________________________________________________________________

Chest/Lungs : _________________________________________________________________________________________

Heart : _________________________________________________________________________________________

Abdomen : _________________________________________________________________________________________

Musculoskeletal : _________________________________________________________________________________________

Neurological : _________________________________________________________________________________________

Skin : _________________________________________________________________________________________

Other : _________________________________________________________________________________________

Impression:

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________ _____________________________
Signature over Printed Name of OPD Head Date

Assessment:

Class A Physically fit for any work

Physically under-developed or with correctible defects, (error of refraction dental carries, defective hearing, and
Class B
other similar defects) but otherwise fit to work

Employable but owing to certain impairments or conditions, (heart disease, hypertension, anatomical defects)
Class C requires special placement or limited duty in a specified or selected assignment requiring follow-up treatment/
periodic evaluation.

Unfit or unsafe for any type of employment (active PTB, advanced heart disease with threatened failure,
Class D
malignant hypertension, and other similar illnesses).

________________________________________________________ _____________________________
Signature over Printed Name of Medical Specialist Date