Physical Examination Report
**TO BE COMPLETED BY A LICENSED PHYSICIAN**
The above named person or applicant is currently employed or will be employed by Samaritan Services Inc. In accordance with Federal and State regulations which require that an annual physical examination for all health care workers be done. Kindly complete, sign and date this form. Thank you.
PLEASE INDICATE DATES AND FINDINGS OF THE FOLLOWING:
Measles/Mumps/ Rubella: MMR Vaccine Given
(If vaccine not given, complete the following:)
(If #1 PPD Negative, must have #2 PPD within 1-3 weeks according to CDC Guidelines)
Are there any physical, psychological or mental limitations which would impair the performance of this employee?
This applicant was interviewed and examined by me. I found his/her health status adequate for work in the health care field. Also, the patient is free from habituation and addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the behavior, or might interfere with the performance his/her duties. The patient is free for any signs or symptoms of active pulmonary Tuberculosis