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Samaritan Physical Examination

Physical Examination Report
**TO BE COMPLETED BY A LICENSED PHYSICIAN**

Employee Name *

Date *

Job Title *

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.

Employee Signature *

Clear

Height *

Sex *

Temp *

Resp *

Weight *

Age *

Pulse *

B/P *

Allergies *

Demonstrates adequate pain-free range of motion of neck, shoulders, wrists, hands, spine, hips knees, ankles:

Yes

Comments

PLEASE INDICATE DATES AND FINDINGS OF THE FOLLOWING:

Measles/Mumps/ Rubella: MMR Vaccine Given *

Yes

Date

(If vaccine not given, complete the following:)

Rubella Titre: Date

Result

Vaccine: Date

Result

Rubeola Titre: Date

Result

Vaccine: Date

Result

Varicella Titre: Date

Result

Drugscreen: Neg *

Pos *

Date *

Hepatitis Vaccine #1

Date

Hepatitis Vaccine #2

Date

Hepatitis Vaccine #3

Date

#1 PPD:
Date Administered

Date Read

(If #1 PPD Negative, must have #2 PPD within 1-3 weeks according to CDC Guidelines)

#2 PPD:
Date Administered

Date Read

*If positive PPD, must have Chest X-Ray
Date Read

Result

Are there any physical, psychological or mental limitations which would impair the performance of this employee? *

Yes

Please explain

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

Signature *

Clear

Date *

Address *

Address

City

State/Province

Zip/Postal

Country

Phone # *

NJ OFFICE (HQ)

NY OFFICE

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