Name sex date of birth



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CHE SENIOR PSYCHOLOGICAL SERVICES

EMPLOYEE HEALTH EXAMINATION FORM
NAME SEX DATE OF BIRTH

Last First
APPLICANT: Have you had any of the following? (Please Check)
High Blood Pressure Epilepsy

Chronic back pains Mental Disease

Tuberculosis Arthritis

Heart Trouble Asthma

Stomach Trouble Skin Disease

Fainting Spells Hernia
Operations: Injuries:

Type:




Height: Weight: Blood Pressure:
Head, ears, eyes, nose and throat:

Neck:

Breasts:

Lungs:

Heart:

Abdomen:

Extremities:

PPD: or Chest X-Ray Date: Results:

Additional Comments:

This individual is approved for employment in a Nursing Home: Yes No

Date: Signature of Examining Physician:

Address:



Phone #:
I herby give permission to CHE Senior Psychological Services, PC/ Psychological Health Services, PC to distribute copies of my health records and information to any required facilities.

Signature:

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