II. In Case of Emergency (Please Contact)

III. Personal/Social History

IV. Past Medical History

V. Hospital Admission / Past Surgical History / Disability

VI. Family History and Immunization

COVID-19 Vaccination Details

VII. Maintenance Medication & OB/GYNE

VIII. HEAD TO TOE ASSESSMENT

IX. APPENDIX A. PHYSICAL EXAMINATION FORM

Please check (/) appropriate box or supply needed information.

I. Physical Screening

II. Physical Examination

Please check (/) Normal and specify abnormal findings.

III. Ancillary Examinations

IV. Employee Classification

V. Evaluating Personnel Remarks