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Embed code for: Elwyn Physical Exam TReeddoc
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Elwyn Staff Physical Examination
_X_ Post-offer bill to Dept. 0009 ___Annual Physical ___Bi-Annual Physical
Health Care Provider Instructions: All sections must be completed due to state and federal regulations. The form will be returned if not complete.
Employee Name: Thomas Reed Physical Date: ____/____/____
Part I – IS THE INDIVIDUAL FREE FROM COMMUNICABLE TUBERCULOSIS AS SHOWN BY:
Was Mantoux- PPD Test administered?
Results read more than 72 hours after date given is not valid
TB tine is not acceptable. If test results are positive, then a chest x-ray must be obtained.
Date Given Lot # Date Read Results Signature
_________ _________ __________ ________ _______________
___Yes ___No Was a Chest X-Ray required?
Date of x-ray Results
Attach copy of results. ___Yes ___No Is the Mantoux-PPD and/or Chest X-Ray contraindicated at this time?
If yes, please give reason:
___Yes ___No Is the individual free from symptoms of communicable diseases?
If no, please explain:
Part II – WORK FITNESS
Is the individual free from any condition that will prevent him/her from performing the essential functions of their position? ___Yes ___No Is the individual free from any health conditions which pose a direct threat to our clients or to our fellow employees or to the individual themselves? ___Yes ___No Specify any task which the individual cannot safely perform without undue risk or harm to self or others.
Please explain all NO answers:
Practitioner’s Name:________________________________________ License #: ______________________
Telephone #:______________________________________________ Date: __________________________
Confirmation of completed General Physical: (Please Circle) YES NO
Signature of Practitioner __________________________________________________________
Rev. 2/2013 Fax to: 610-891-2900