Occupation Agency Code Work Location Work Supervisor Duty tel. #
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1 PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal or regulatory investigations or prosecutions. The Social Security Number, authorized by Public Law Section 7 (b) and Executive Order 9397, is used as a unique identifier to distinguish between employees with the same names and birth dates and to ensure that each individual's record in the system is complete and accurate and the information is properly attributed. Employee info: Occupation Agency Code Work Location Work Supervisor Duty tel. # Visit for: PERIODIC FORKLIFT OPERATOR / MATERIAL HANDLING EQUIPMENT 710 CERTIFICATION EXAMINATION Medical History 1. Is your work exposure history current (OPNAV 5100/15), and is surveillance/ppe consistent with exposures/occupations 2. Has anything about your health status changed since your last examination 3. Have any medications changed since your last exam 4. Major illness or injury 5. Hospitalization or surgery 6. Cancer 7. Back injury 8. Do you drink 6 or more drinks per week (beer, wine, liquor) 9. Have you ever smoked 10. Do you currently smoke or use smokeless tobacco or electronic cigarettes ( packs/day) 11. Heart disease, high blood pressure, stroke or circulation problems 12. Current medication use (prescription or over the counter) 13. Medication allergies 14. Any reproductive health concerns 15. Headache, dizziness, light headedness, weakness 16. Head injury 17. Change or loss of vision in either eye 18. Change or loss in hearing 19. Chest pain, angina, heart attack, irregular heart beat (arrhythmia), palpitation, or other heart problem 20. Repeated episodes of loss of or near loss of consciousness 21. Epilepsy or seizures 22. Problems with balance or coordination 23. Numbness, tingling, or weakness in hands or feet 24. Diabetes (sugar disease) or other endocrine disorder (thyroid, parathyroid, pituitary, adrenal gland) 25. Mental or emotional illness 26. Depression, difficulty concentrating, excessive anxiety 27. Personality or behavior change Page 1 of 5 Do not re-use this form after 11/14/2017
2 Medical History (continued) Comments on Medical History: Page 2 of 5 Do not re-use this form after 11/14/2017
3 Studies and Immunizations Audiogram (non-hcp) Vision With Correction Without Correction DISTANCE NEAR Right Left Both Right Left 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / Visual fields Horizontal (lateral) field of vision, degrees Right Left Color vision Pass Fail Ishihara - # of plates HRR (Hardy Rand Ritter) City University Farnsworth D15 Other Depth perception Pass Fail Test used: Comments on Studies, Immunizations, and Vision: Page 3 of 5 Do not re-use this form after 11/14/2017
4 Vital Signs Blood pressure: Pulse: Respiratory rate: Temperature: Height: Weight: Physical Examination Eyes Ears (tympanic membranes) Cardiovascular system Back & musculoskeletal system Central nervous system Peripheral nervous system (strength, sensation, DTRs) WNL Other (describe) Comments on Physical Exam findings: Page 4 of 5 Do not re-use this form after 11/14/2017
5 Assessment Certification Examinations Qualified Not Qualified Pending FORKLIFT OPERATOR / MATERIAL HANDLING EQUIPMENT (710) Disposition and Follow-up Released from Occupational Health Clinic Follow-up with PCM on or in Return for follow-up exams: FORKLIFT OPERATOR / MATERIAL HANDLING EQUIPMENT in 1 year. Other disposition: Discussed results of exam with employee Limitations and comments: Provider Signature & Stamp: Date: Page 5 of 5 Do not re-use this form after 11/14/2017
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
REDDY & ASSOCIATES LLC D/B/A Reddy Medical Group D/B/A Reddy Urgent Care. Reddy Urgent Care Pre-Employment Physical Form
REDDY & ASSOCIATES LLC D/B/A Reddy Medical Group D/B/A Reddy Urgent Care 132 Franklin Springs St. 1061 Dowdy Road STE 100 280 General Daniels Ave. Royston, GA 30662 Athens, GA 30606 Danielsville, GA 30633
medical questionnaire Date: Day Month Year
medical questionnaire Date: Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you
Medical Questionnaire
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Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
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Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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