Healthcare Health Examination Report

HEALTH EXAMINATION REPORT

Patient Information

Patient Name:   Date of Birth:   Gender:

Phone:   Email:

Emergency Contact

Relationship:   Phone:

Insurance Information

Policy Number:   Group Number:

Subscriber Relationship:

Medical History

Tobacco Use:   Alcohol Use:   Pregnancy Status (if applicable):

Vital Signs & Measurements

Height:   Weight:   BMI:

Blood Pressure:   Pulse:   Respiratory Rate:

Temperature:   Oxygen Saturation:

Physical Examination — System Findings

Diagnostic Tests / Screenings Performed

Assessment, Diagnosis & Plan

Follow-up Date (if indicated):

Fitness / Work Status

 Fit for duty without restrictions      Fit for duty with restrictions      Not fit for duty / temporary or permanent work restrictions

Privacy & Authorization

This Health Examination Report contains confidential medical information. It is intended for the use of authorized personnel only. By signing below, the patient authorizes release of this report to the requesting party for the stated purpose and affirms that the information provided is accurate to the best of the patient's knowledge. The patient may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it.

 I acknowledge receipt of the Notice of Privacy Practices and authorize release of my health information as described above.

Authorization Expires:

Examiner / Facility Information

Facility / Provider Name:

Clinician Printed Name:   License / Credentials:

Clinic Address:

Clinic Phone:   Date of Examination:   Time of Examination:

Certification: I hereby certify that the information contained in this report is complete and accurate to the best of my knowledge and that the examination described above was conducted by me or under my direct supervision.

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