Physical Assessment Examination Name: ______________________________________________________ Date: ___________________________________ Duration of employment: ________________________________________________________________________________ Job title: _______________________________________________________________________________________________ Description of job: ______________________________________________________________________________________ Age: ____________ Gender: ____________ Marital status: _____________ Race: _____________ Person to contact in emergency: ___________________ Phone number: _________________ Allergies or adverse reactions (e.g., food, medicine): ❑ None known Source Reaction ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Pre-existing conditions, previous surgery, procedures: ________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Medications taken at home (OTC, prescription): _____________________________________________________________ Name Dose/Frequency Time Reason for use 1. ____________________________________________________________________________________________________ 2. ____________________________________________________________________________________________________ 3. ____________________________________________________________________________________________________ Do you experience any problems from your medication? ❑ Yes ❑ No ____________ Do you use tobacco? ❑ No ❑ Yes (type) ______________ Amount ______________ Duration ______________ Vital Signs B/P __________ R Arm Temperature ___________ Height _______________ (ft/in) (actual/stated) __________ L Arm Heart Rate ____________ Weight _______________ Respirations ___________ (lb) (actual/stated) 323 Guideline continues on next page