Non-Dot Physical Form

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Company Name*:

Last Name*

First Name*

Middle Name*

Sex

Age

Exam Date

Address*

City*

State*

Zip*

Phone

JOB TITLE* (MUST BE COMPLETED OR EXAM CANNOT BE DONE)

DATE OF BIRTH*

SSN*

The history you give and the physical examination performed by the health care provider are important to you. Please answer all questions in parts A and B. If you do not understand a question, leave the answer blank and ask the health care provider at the time of your evaluation. I hereby authorize CCOH to release copies of my medical records to my employer. This form should be kept separately from your personnel file. I also release CCOH from any liability arising from such disclosure. The information you authorize for release may include records which may indicate the presence of communicable or sexually transmitted diseases which may include, but are not limited to the following: Hepatitis, Syphilis, Gonorrhea, Human Immunodeficiency Virus (HIV), and Acquired Immune Deficiency Syndrome (AIDS).

PART A- PRESENT HEALTH

PARTICIPANT: PLEASE COMPLETE BY ANSWERING EACH QUESTION.

DETAILS TO “YES” ANSWER –LIST ITEM NUMBER.

PART B-MEDICAL HISTORY

HAVE YOU EVER HAD OR HAVE YOU NOW

PART B-MEDICAL HISTORY CONT.

HAVE YOU EVER HAD OR HAVE YOU NOW

Signature:

Please sign your name above and save signature, and then submit the form below.

Date*:

If YOU ANSWERED “YES” TO ANY QUESTIONS IN THE “MEDICAL HISTORY” PLEASE EXPLAIN BELOW:

Select Location*