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Health Assessment
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Employee
Employee ID
Assessment Date
Type
Result
Doctor
Notes
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Employee
Assessment
Vitals
Vision & Hearing
Labs & Vaccines
History
Physical Exam
Fitness Decision
Signatures
Employee Name
Employee ID
Department
Job Title
Assessment Date
Assessment Type
Select type
Pre-employment
Periodic
Return to Work
Fitness for Duty
Exit
Other
Location/Clinic
Doctor
Doctor License No.
Next Review Date
Chief Complaint / Reason
Height (cm)
Weight (kg)
BMI
BP Systolic
BP Diastolic
Pulse (bpm)
Temperature (°C)
Respiratory Rate
SpO₂ (%)
Blood Sugar (mg/dL)
Visual Acuity
Left (Unaided)
Right (Unaided)
Left (Aided)
Right (Aided)
Color Vision
Select
Normal
Deficient
Vision Notes
Hearing
Left Ear
Select
Pass
Fail
Right Ear
Select
Pass
Fail
Audiometry (if available)
Laboratory Results
Hemoglobin (g/dL)
WBC (10^9/L)
Platelets (10^9/L)
Fasting Glucose (mg/dL)
Cholesterol (mg/dL)
Liver Function
Renal Function
Other Labs
Vaccinations
Tetanus
Hepatitis B
Influenza
Past Illnesses
Surgeries
Allergies
Current Medications
Smoking
Select
No
Yes
Former
Alcohol
Select
No
Yes
Occasional
Occupational Exposure
General Appearance
Head/Neck
Cardiovascular
Respiratory
Abdomen
Musculoskeletal
Neurological
Skin
Result
Select
Fit
Fit with Restrictions
Temporarily Unfit
Permanently Unfit
Restrictions (if any)
Notes
Doctor Name
Doctor Signature Date
Employee acknowledges review