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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