PRE-EMPLOYMENT PHYSICAL
Occupational health assessment after a conditional job offer

Candidate: [Name, date of birth]
Date of assessment: [Date, or each date if tests ran over more than one visit]
Employer: [Organization, and the contact who receives the outcome]
Job offered: [Job title, department, start date]
Conditional offer: [Date of the offer letter or the employer's referral]
Examiner: [Name, credentials, clinic]
Consent: [Consent to the assessment, and to the outcome going to the employer; what the employer will and won't receive, explained]

JOB DEMANDS
Source: [Employer's job description or physical demands analysis, with its date]
Physical: [Weights lifted, from what height to what height, how often; carrying, pushing, standing, walking, climbing, kneeling]
Senses: [Vision, color vision, or hearing the job needs]
Schedule and mental demands: [Shift length, nights, working alone, safety-critical decisions]
Exposures: [Noise, respirator use, blood and body fluids, chemicals, dust, heat, cold, heights]
Vehicles and equipment: [Driving, forklifts, powered pallet jacks, machinery, or none]

HEALTH HISTORY
Conditions that bear on the job: [Past injuries, surgery, heart, lung, seizure, sleep, or other conditions relevant to the demands above, with current status]
Past work injuries or restrictions: [Dates, what happened, any restriction still in place]
Medications: [Each medicine; any that cause drowsiness or affect safety-critical work]
Allergies: [Medicines, latex, or none]
Current symptoms: [Pain, breathlessness, or none]

IMMUNIZATIONS AND TB, WHEN THE JOB NEEDS THEM
Immunity: [Each vaccine or blood test the employer's policy asks for, with dates and results]
Given today: [Vaccines given and any follow-up due, or none]
TB screening: [Risk questions, symptom screen, test type, dates placed and read or drawn, result; chest X-ray if positive]

VISION AND HEARING
Visual acuity: [Right and left, with or without correction, chart used]
Color vision and visual fields: [Result, when the job needs them, or not required]
Hearing: [Whispered voice result, or a baseline audiogram for jobs in a noise program]

VITAL SIGNS
Blood pressure and pulse: [Reading, and a repeat after rest if high]
Height, weight, and BMI: [Measurements]

FOCUSED EXAMINATION
[The systems the job's demands call for: spine, shoulders, knees, heart, lungs, skin of the hands, nerves; findings with side, range of motion, and strength]

JOB-SPECIFIC TESTS
Lifting or functional test: [Task, weight, start and end height, repetitions, who tested, result]
Respirator clearance and fit test: [Questionnaire reviewed, spirometry if indicated, model and size passed, or not required]
Audiometry or spirometry for exposure programs: [Result, or not required]
Drug or alcohol test: [Only if the employer's program requires it: type, collection date, result after review, or not part of the program]

OUTCOME FOR THE EMPLOYER
Outcome: [Fit; fit with restrictions or accommodations; not fit; or pending, with what it waits on]
Restrictions or accommodations: [Each one in work terms: weight, height, frequency, hours, tasks; or none]
How long: [Temporary until a date, or permanent]
Review: [Date and what will be repeated, or none needed]
Also shared, if the job's program needs it: [Respirator clearance, fit-test model, immunity status meets policy, or nothing else]

CLINIC RECORD ONLY
Not sent to the employer: [Health history, diagnoses, test results, and exam findings]
Advice to the candidate: [Findings to follow up with their own clinician, or none]
Regulated job: [If a regulator sets its own medical standard, such as for commercial driving or flying, the regulator's form and recognized examiner used; or not applicable]

Signed: [Examiner name, credentials, date]