Employee Physical Examination Questionnaire

Collect a worker's personal details, measurements, medical history, and habits, along with supporting files and the examiner's signature. Designed for occupational health clinics that verify staff fitness for duty.

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Section

Staff Name

Nombre

Apellido

Gender

Female Male Other Prefer not to say

Job Title

Date of Birth

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Section

Height

Weight

Tobacco Use

Never Former smoker Occasional Daily

Past Medical History

Hypertension Diabetes Asthma Heart disease Allergies None

Please provide a more detailed explanation

Upload Staff Medical Files

Max 10 MB per file

Date

Examiner Name

Nombre

Apellido

Examiner Signature

Sign here

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