Direct Personal Care

T: 718.847.8800 | C: 646.464.4473

T: 718.618.9049 | F: 718.847.7800

E:directpersonaltare@gmail.com | www.directpersonalcares.com

119-40 Metropolitan Ave. Jamaica, NY 11415

INITIAL PHYSICAL EXAM FORM

Name D.O.B.

ADDRESS:
Medical History:
Family History:

SocialHabits: AlcoholTobaccoDrugs History of Substance Abuse

Physical Findings:

Height Weight

Heart: Lungs: Abdomen: Other:
Blood Pressure:
Pulse:
Reg.
Irreg. Respiration:

Lab Results:* *Office must have a copy of the actual Laboratory Results to attach or insert the actual lab values on this form.

VACCINATIONS: If results are NEGATIVE, Vaccination is MANDATORY

Rubella Tittle: Date: Findings: Immune YesNo: Non-immune Status must have vaccine
Vaccination Date # 1:
Vaccination Date # 2:

Rubeola Title (if born after 1957) Date: Findings: Immune YesNo: Non-immune Status must have vaccine

Non -immune Status must have vaccine
Vaccination Date # 1:
Vaccination Date # 2:
ANNUAL INFLUENZA VACCINE: Date:

PPD: Date Given: Date Read:Reactive Yes(+)No(-)

IF PPD is Positive please attach CHEST X-RAY REPORT Date: Results:

Valid for a 5-year period without any new TB symptoms.
I certify that the abovenamed person is free from health impairments which are of potential risk to clients, families or other employees or which might interfere with the performance of his/her duties and is able to work with no restrictions. If no, please explain.

Examiner's Signature Date

Examiner's Name Printed: Examiner's Telephone #