Attmt 9 Candidate Medical Exam_01072026.pdf

INSTRUCTIONS FOR CONDUCTING THE CUSTOMS AND BORDER PROTECTION (CBP) MEDICAL EXAM

Do not provide the examinee with any exam results or facility paperwork indicating normal or abnormal testing results.

ADMINISTRATIVE/CLINICAL STAFF:

Ensure the candidate completes ALL medical history questions, with dates and explanation for any “YES” answers.

Name, last 4 digits of social security number, and date of service are required on the top of every page VA disability or non-VA disability o If yes, include breakdown of VA rating decision o Complete all questions in full

Medical History Form MUST be signed and dated by candidate Vision Testing o Depth Perception – Document type of test used, total number of correct responses and seconds of arc or % Shepard Fry. If results are > 70 Seconds of Arc, re-explain procedure and retest.

o Peripheral Vision – Temporal and Nasal results are both required o Visual Acuity – Corrected and Uncorrected, near and far are required if candidate wears corrective lenses. If does not correct to 20/20; re-explain procedure and retest.

o Color vision – Complete HRR 4th edition. Record candidate responses.

o Include printed name and signature of examiner

Audiology Testing o Document calibration type and date o Document Canal/External Ear and Tympanic Membrane results

Body Measurements: Document height and weight Vitals o Repeat pulse if 100 or greater o Repeat blood pressure if greater than 140/90

Clinical Evaluation: MD/DO name and signature are required

EXAMINING PHYSICIAN:

If ANY orthopedic injury or illness has occurred, document each injury on attached examiner section Flexibility Evaluation: Explain all abnormal responses.

MD/DO MUST co-sign paperwork if exam completed by NP or PA Printed name, signature and credential of examining physician are required

Verify that all testing and examinations are completed PRIOR TO THE APPLICANT LEAVING THE CLINIC.

Incomplete medical findings or improperly prepared paperwork MAY RESULT IN NON-PAYMENT

Contact a Client Service Administrator at xxxx for questions PRIOR TO the examinee leaving the office.

FAX COMPLETED EXAMINATION PAPERWORK WITH AUTHORIZATION AS COVER TO

xxxx IMMEDIATELY AFTER THE COMPLETED APPOINTMENT

MEDICAL EXAMINATION AND HISTORY REPORT

CANDIDATES: Please DO NOT write in “EXAMINING FACILITY USE ONLY” areas.

CANDIDATES: Complete page 1 through 5 before reporting for the medical examination. Failure to answer any questions or disclose a known medical condition or failure to place signature where indicated may result in disqualification from employment consideration. Please print or type. Each “yes” answer to a medical history question requires that you provide a brief explanation in the comment section provided. This examination is being conducted for employment purposes only; it does not substitute for a periodic health examination conducted by your private provider.

All mental health counseling must be disclosed on this Medical Examination and History Report form in order to determine if you meet the minimum medical qualifications for the position.

CANDIDATE’S NAME (Last, First, Middle Initial): Last 4 SSN:

VETERAN’S PREFERENCE ELIGIBILITY: ☐ Yes ☐ No SEX: ☐ Male ☐ Female

DATE OF BIRTH:

(mm/dd/yy)

YOUR CURRENT OCCUPATION: YOUR CURRENT EMPLOYER:

HOW LONG IN CURRENT POSITION? (years/months)

DESCRIBE TASKS OF YOUR CURRENT POSITION (mainly sedentary, very physically demanding, etc.)

CHECK THE OCCUPATION FOR WHICH YOU ARE BEING CONSIDERED:

☐ Border Patrol Agent ☐ Agriculture Specialist

☐ Customs and Border Protection Officer ☐ Other:

EXAMINING FACILITY USE ONLY

EXAMINING FACILITIES: (Do NOT bill examinee for exam. CHS is responsible for all payments.) Conduct medical exam and all other required services in accordance with instructions provided by the contracting organization. Complete this form except where indicated. Please print or type.

NAME AND ADDRESS OF EXAMINING FACILITY:

DATE OF EXAMINATION:

NAME OF EXAMINING PHYSICIAN/NP/PA:

PHONE NUMBER: (including area code)

REQUIRED SERVICES: (check when completed and attach reports)

☐ Medical History and Examiner Review ☐ Audiometry

☐ General Physical Examination (including waist measurements and fitness questionnaire)

☐ Repeat Audiometry, if appropriate

☐ Examiner Review and Comments

☐ Vision Screening

CANDIDATE’S NAME:

Last 4 SSN:

DATE:

MEDICAL HISTORY

Candidate Complete This Section

Check “yes” or “no” for each item. For each “yes”, you must provide an explanation in the space below. Explanations to “yes” answers must include date, body part affected, description of injury/issue, and type of treatment.

1. Have you ever been refused employment or been unable to hold a job or stay in school due to any medical condition? (If yes, specify date, what was the issue/treatment, date issue was resolved or if it continues)

☐ Yes ☐ No

2. Have you had any surgery or operation? (If yes, describe and give date, name of procedure, date of recovery)

3. Have you been advised to have any surgery or operation, but chose not to have that treatment? (If yes, describe and give date, details or problems, and name of procedure)

4. Have you ever been a patient in any type of hospital or emergency room? (If yes, specify date, where, why)

5. Have you consulted with or been treated by clinics, physicians, healers, or other practitioners other than for minor illness? (If yes, give date, where and why)

6. Have you ever been rejected for or separated from military service because of physical, mental or other medical reasons? (If yes, give date and reason)

7. Have you ever applied for or received VA (Veteran’s Administration) disability? (If yes, please attach a copy of all rating decisions, or application if pending decision)

Percentage Granted: ________________ % Year(s) Granted: _________________

Issue and Related Percentage (for example, PTSD 50%, etc.):

Candidate Complete This Section

8. Have you ever applied for or received pension or compensation for a non-VA disability (e.g., Workers’ Compensation, Social Security Disability, etc.)? (If yes, please attach a copy of all rating decisions, or application if pending decision)

Type of Disability (SSDI, Worker’s Comp, etc.):

Permanent or Temporary: ________________ Percentage Granted: _______% Year(s) Granted: ________

Issue and Related Percentage:

9. Are you: ☐ Left-Handed OR ☐ Right-Handed

10. Do you take any medications?

If yes, list prescription and non-prescription medications, dosage, and reason for taking.

Medication Dosage/Frequency Reason Side effects? Currently Taking Taken in the Last Year

1. ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

2. ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

3. ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

4. ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No *Attach additional sheets if necessary. Describe all side effects.

11. Do you use inhalers?

If yes, list prescription and non-prescription medications, dosage, and reason for taking.

Medication Dosage/Frequency Reason Side effects? Currently Taking Taken in the Last Year

1. ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

2. ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

3. ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

4. ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

*Attach additional sheets if necessary. Describe all side effects.

12. Have you ever had an anaphylactic (or near anaphylactic) allergic reaction to a bee sting?

If yes, do you carry an epi pen/spray?

13. Have you ever had an anaphylactic (or near anaphylactic) allergic reaction to any foods?

If yes, is the reaction only when you ingest the food?

Do you carry an epi pen/spray?

☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

14. Have you ever had an anaphylactic (or near anaphylactic) allergic reaction to anything else?

If yes, what caused the reaction?

Do you carry an epi pen/spray?

Candidate Complete This Section

Have you ever experienced any of the following? Describe all YES answers on page 5.

15. Diabetes ☐ Yes ☐ No 39. Epilepsy or seizures ☐ Yes ☐ No

If yes, do you use: ☐ Pills ☐ Insulin ☐ Insulin Pump If yes: How many seizures have you had?

☐ Yes ☐ No

What is the date of onset? When was last episode? ☐ Yes ☐ No

16. Current hypoglycemia symptoms ☐ Yes ☐ No What caused symptoms? ☐ Yes ☐ No

17. Current thyroid disease ☐ Yes ☐ No 40. Localized weakness/numbness ☐ Yes ☐ No

If yes: Date of Diagnosis? ___________________________ If yes, how often? ___________________________________ Treatment changes in past 6 months?

☐ Yes ☐ No When was last episode? ______________________________

Current symptoms? ________________________________ What causes symptoms? _____________________________

18. Blood disorder ☐ Yes ☐ No 41. Tremors/shakiness ☐ Yes ☐ No

19. Anemia in past year ☐ Yes ☐ No How often? ________________________________________

20. Back pain/injury/surgery ☐ Yes ☐ No Date of last episode__________________________________

21. Neck pain/injury/surgery ☐ Yes ☐ No When do episodes occur? ____________________________

22. Shoulder pain/injury/dislocation surgery ☐ Yes ☐ No Type of tremors _____________________________________

23. Shoulder dislocation? ☐ Yes ☐ No 42. Fainting/syncope/loss of balance or consciousness/dizziness ☐ Yes ☐ No

If yes: Number of dislocations: _______________________ How often? ________________________________________ Date of most recent dislocation: ______________________ Date of last episode _________________________________ Surgically repaired? ☐ Yes ☐ No What causes symptoms? _____________________________ Date of repair_____________________________________ 43. Traumatic Brain Injury (TBI) symptoms

/diagnosis or treatment in past year ☐ Yes ☐ No

Current symptoms? ☐ Yes ☐ No If Yes: Date of diagnosis: _____________________________ Current treatment? ☐ Yes ☐ No Symptoms: ________________________________________

24. Arm pain/injury/surgery ☐ Yes ☐ No Frequency: ________________________________________

25. Elbow pain/injury/surgery ☐ Yes ☐ No What causes symptoms? _____________________________

26. Wrist pain/injury/surgery ☐ Yes ☐ No 44. Persistent stomach/abdominal pain ☐ Yes ☐ No

27. Hand pain/injury/surgery ☐ Yes ☐ No 45. Diagnosed Irritable Bowel Syndrome (IBS)

Inflammatory Bowel Disease (IBD), Crohn’s Disease, Ulcerative Colitis, etc. symptoms or treatment in past 6 months

☐ Yes ☐ No

28. Hip pain/injury/surgery ☐ Yes ☐ No

29. Leg pain/injury/surgery ☐ Yes ☐ No

30. Knee pain/injury/surgery ☐ Yes ☐ No If yes: Date of diagnosis______________________________

31. Ankle pain/injury/surgery ☐ Yes ☐ No Symptoms: ________________________________________

32. Foot pain/injury/surgery ☐ Yes ☐ No Frequency: ________________________________________

33. Loss of joint/limb movement/amputation ☐ Yes ☐ No Severity: __________________________________________

34. Arthritis ☐ Yes ☐ No How do you treat your symptoms? _____________________

If yes, type: ______________________________________ 46. Liver disease ☐ Yes ☐ No Date of diagnosis _________________________________ If yes: Date of diagnosis______________________________ Symptoms: ______________________________________ Symptoms: ________________________________________ Body part(s) affected: ______________________________ How do you treat your symptoms? _____________________

35. Current gout symptoms ☐ Yes ☐ No 47. Hepatitis ☐ Yes ☐ No

36. Kidney disease ☐ Yes ☐ No If viral, specify A, B, or C ___________________________

If yes, specify type of disease: ________________________ Date of diagnosis_________________________________ Date diagnosed: ___________________________________ Symptoms: ______________________________________

37. Current kidney stones ☐ Yes ☐ No Frequency: ______________________________________

38. Diagnosed migraine headache ☐ Yes ☐ No Severity: ________________________________________

If yes, how often? __________________________________ How do you treat your symptoms? ___________________ When was last episode? _____________________________ Are you able to work during a migraine? ________________

Have you ever experienced any of the following? Describe all YES answers on page 5.

48. Hernia ☒ Yes ☐ No 64. HIV diagnosis ☐ Yes ☐ No

If yes, hernia type: _______________________________ If yes: Date of diagnosis _____________________________

Surgically repaired? ______________________________ 65. Cardiac related chest pains ☐ Yes ☐ No Date of surgery _________________________________ If yes: Frequency: _________________________________ Current symptoms? ______________________________ Date of last symptoms: _____________________________

49. Mental health treatment, psychotherapy or counseling

☐ Yes ☐ No What causes symptoms? ____________________________

50. Diagnosed ADD/ADHD treated in past 5 years

☐ Yes ☐ No How do you treat symptoms? ________________________

51. Diagnosed depression ☐ Yes ☐ No 66. Peripheral Vascular Disease ☐ Yes ☐ No

52. Diagnosed anxiety ☐ Yes ☐ No 67. Mitral valve prolapse ☐ Yes ☐ No

53. Diagnosed PTSD ☐ Yes ☐ No 68. History of diagnosis or heart disease ☐ Yes ☐ No

54. Diagnosed insomnia ☐ Yes ☐ No 69. Coronary bypass surgery/other heart surgery ☐ Yes ☐ No

55. Any other mental health diagnosis ☐ Yes ☐ No If yes: Surgery date: ________________________________

56. Treatment for alcoholism or substance abuse

☐ Yes ☐ No Current symptoms? ☐ Yes ☐ No

57. Suicide ideation, attempts or plans ☐ Yes ☐ No Current treatment? ☐ Yes ☐ No

58. Severe skin problems that cannot be managed?

☐ Yes ☐ No 70. Heart palpitations (rapid or skipped heartbeat) ☐ Yes ☐ No

59. Organ transplant recipient (e.g. kidney, etc.).

☐ Yes ☐ No If yes: Frequency: _________________________________

If yes: Which organ ________________________________ Date of last symptoms: _____________________________ Date of transplant _________________________________ What causes symptoms? ____________________________ Current symptoms? ☐ Yes ☐ No How do you treat symptoms? ________________________ Current treatment? ☐ Yes ☐ No 71. Heart attack or stroke ☐ Yes ☐ No

60. Organ donor (e.g. kidney, etc.) ☐ Yes ☐ No If yes: Date: ______________________________________ If yes: Which organ? _______________________________ Current symptoms? ☐ Yes ☐ No Date of transplant _________________________________ Current treatment? ☐ Yes ☐ No Current symptoms? ☐ Yes ☐ No 72. Abnormal electrocardiogram (EKG) ☐ Yes ☐ No Current treatment? ☐ Yes ☐ No If yes: Date: ______________________________________

61. Heat stroke/heat exhaustion ☐ Yes ☐ No Current symptoms? ☐ Yes ☐ No If yes, Number of episodes __________________________ Current treatment? ☐ Yes ☐ No Date of most recent episode ________________________ 73. Abnormal cardiac stress test ☐ Yes ☐ No Describe what led to symptoms _____________________ If yes: Date: ______________________________________ Current symptoms? ☐ Yes ☐ No Current symptoms? ☐ Yes ☐ No Current treatment? ☐ Yes ☐ No Current treatment? ☐ Yes ☐ No

62. Rhabdomyolysis ☐ Yes ☐ No 74. Sleep apnea ☐ Yes ☐ No If yes, Number of episodes: __________________________ If yes: Date: ______________________________________ Date of most recent episode _________________________ Current symptoms? ☐ Yes ☐ No Describe what led to symptoms _______________________ Current treatment? ☐ Yes ☐ No Current symptoms? ☐ Yes ☐ No CPAP recommended ☐ Yes ☐ No Current treatment? ☐ Yes ☐ No CPAP used ☐ Yes ☐ No

63. Cancer diagnosis ☐ Yes ☐ No 75. Diagnosis of hypersomnolence/narcolepsy ☐ Yes ☐ No If yes: Which type__________________________________ If yes: Date: ______________________________________ Date of diagnosis __________________________________ Current symptoms? ☐ Yes ☐ No Current symptoms? ☐ Yes ☐ No Current treatment? ☐ Yes ☐ No Current treatment? ☐ Yes ☐ No 76. Raynaud’s Disease ☐ Yes ☐ No In Remission? ☐ Yes ☐ No If yes: Date: ______________________________________ Date of remission __________________________________ Current symptoms? ☐ Yes ☐ No

Last 4 SSN

Have you ever experienced any of the following? Describe all YES answers on page 5.

77. Phlebitis or blood clots diagnosed or treated within past 2 years ☐ Yes ☐ No 85. Have you ever had, or are you currently being treated for any other illness or injury not already mentioned.

☐ Yes ☐ No

If yes: Date: _____________________________________ Current symptoms? ☐ Yes ☐ No If yes, describe details and dates:

Current treatment? ☐ Yes ☐ No

What caused the symptoms? ________________________ 86. Do you have any current lifting restrictions? ☐ Yes ☐ No

78. Current problems with breathing, wheezing, or persistent cough ☐ Yes ☐ No If yes, describe:

If yes: Date of most recent symptoms ________________ 87. Over the past six weeks, on average, how many times per week have you been running? _______ times per week Current symptoms? ☐ Yes ☐ No

Current treatment? ☐ Yes ☐ No 88. What is the average distance of your run? _____ miles

89. How many minutes do you usually run without stopping?

_______________ minutes 79. Asthma diagnosed/treated in past year ☐ Yes ☐ No If yes: Date: ____________________________________ 90. Describe your current training regimen for the past month including running (distance, location, frequency), calisthenics (type of exercise and frequency), weight training (type of training, weight used, frequency, duration). Use additional pages as needed.

Current symptoms? ☐ Yes ☐ No Current treatment? ☐ Yes ☐ No

80. Previous positive TB skin test ☐ Yes ☐ No If yes, date of positive test: ________________________ Have you had a negative chest x-ray since your positive test?

☐ Yes ☐ No

Date of negative chest x-ray _______________________ Current symptoms? ☐ Yes ☐ No Current treatment? ☐ Yes ☐ No

81. Color vision problems ☐ Yes ☐ No

82. Have you ever had eye surgery?

(e.g. RK, PRK, LASIK, cataracts, detached retina)

☐ Yes ☐ No

If yes, specify surgery and date _______________________ 91. Do you have any residual symptoms with exercise (such as pain, swelling, exercise intolerance)?.…

☐ Yes ☐ No

83. Do you wear corrective lenses (glasses)? ☐ Yes ☐ No

If yes: for distance or near? __________________________ If yes, describe symptoms:

84. Do you wear contact lenses? ☐ Yes ☐ No

If yes: for distance or near? ________________________ 92. This is a very physically demanding job. Do you have any medical issues not already discussed that will prevent you from safely and efficiently performing all job tasks?

If yes: do you wear soft contacts ☐ Yes ☐ No Date started: ____________________________

☐ Yes If yes, please describe:

☐ No. I do not have any medical issues that will prevent me from safely and efficiently performing all job tasks.

CANDIDATE AND EXAMINER COMMENTS

Candidate and Examiner to Complete This Section

For all “yes” answers from prior pages, explain in detail. Use additional sheets if needed.

APPLICANT EXAMINER

Question Number

Date of Injury/Date of Diagnosis (month/year)

How injury/illness occurred, symptoms, body part affected, type of treatment, current symptoms, etc.

Examiners Comments

I certify that the above information provided is complete and correct to the best of my knowledge. I understand that failure to answer any questions or disclose a known medical condition or failure to place signature where indicated may result in disqualification from employment consideration.

CANDIDATE’S SIGNATURE:

VISION ASSESSMENT

For all “yes” answers from prior pages, explain in detail. Use additional sheets if needed.

DEPTH PERCEPTION PERIPHERAL VISION

Check test used: RIGHT LEFT

☐ Titmus Stereo ☐ Titmus Vision Screener Temporal ____° Temporal ____° ☐ If other, name of test: _______________ Nasal ____° Nasal ____°

____ of ____ total number Total ____° Total ____° Document the number of correct responses above. (Total Normal: typically, 115° or greater) (Total Normal: typically, 115° or greater)

____ Seconds of Arc OR ___% Shepard-Fry

If results are > 70 Seconds of Arc, re-explain procedure and retest.

Check test used:

☐ Titmus Stereo ☐ Titmus Vision Screener ☐ If other, name of test: _______________

____ of ____ total number Document the number of correct responses above.

____ Seconds of Arc OR ___% Shepard-Fry

VISUAL ACUITY

TEST ADMINISTRATOR PLEASE NOTE: If the vision testing method only tests to 20/200, state “worse than 20/200.” Do NOT use symbols (less than “<” or greater than “>”) when documenting visual acuity scores

UNCORRECTED VISION (SNELLEN UNITS) Applicant must remove glasses/contacts

DISTANCE Right: 20/____________ Left: 20/___________ BOTH: 20/______ NEAR Right:20/____________ Left: 20/___________ BOTH: 20/______

CORRECTED VISION (SNELLEN UNITS) Applicant wearing glasses/contacts.

DISTANCE Right: 20/____________ Left: 20/___________ BOTH: 20/______ NEAR Right:20/____________ Left: 20/___________ BOTH: 20/______

CORRECTED VISION (RETEST ONLY) IF APPLICANT CANNOT CORRECT TO 20/20; re-explain procedure and retest.

DISTANCE Right: 20/____________ Left: 20/___________ BOTH: 20/______ NEAR Right:20/____________ Left: 20/___________ BOTH: 20/______

Examiner printed name

Examiner Signature

Date

COLOR VISION TESTING: HRR 4th EDITION

PREPARATION:

Keep the test book closed when not in use.

Do not touch the plates/pages with your fingers; turn the pages by the tabs.

Seat the examinee so that their eyes are kept about 30 inches from the book when it is placed on the table. Record all answers on the provided score sheet.

Turn on the light source and exclude from the room most extraneous light that would fall directly on the test. Test binocularly (both eyes viewing at the same time).

NOTE: Color corrective/tinted glasses or color corrective/tinted contact lenses are NOT PERMITTED.

DEMONSTRATION:

The demonstration plates/pages (1-4) are used to show the examinee what to do and to explain how the test is done. Please complete plates/pages 1-4 with the examinee. Show these four plates in sequence saying; “I am going to show you some colored symbols. Without touching them, how many do you see? What shapes do you see? Where are they?”

Say, “For example, your answer may be – two symbols, a Circle and a Triangle, the Circle is upper right and the Triangle is lower left." Unless the examinee is malingering or totally color deficient, two colored symbols should be seen on each of the first two demonstration plates (O, X and △), one colored symbol (O) on the third plate, and no colored symbol on the fourth demonstration plate.

Tell the examinee that these symbols may appear in any of the four corners of the page.

Ask the examinee to trace the symbols they see with the small brush. Then say: “The test itself is made up of just these three symbols with two, one, or none on a page. Some of them will be harder for you to see as they may be less strong in

DEMONSTRATION PLATES/PAGES

How many colored symbols do you see? What do you see?

Where are they?

Check here if no symbol seen

How many colored symbols do you see? What do you see?

Where are they?

Check here if no do you see? What do you see?

Where are they?

Check here if no do you see? What do you see?

Where are they?

Check here if no

SCREENING:

NOTE: These instructions are specific to this particular client, COMPLETE ALL 24 plates/pages. Be aware the plate/page numbers are on the BACK of the corresponding page.

Ask “How many colored symbols do you see on the page? What are the symbols? Where are the symbols?”

Obtain a quick response from the examinee but take your time carefully recording the response (using X, O, △) in the box provided for each plate on the Scoring Sheet. Record the exact symbols seen in the location indicated by the examinee or place a check in the small box if no symbol is seen.

INCORRECT RECORDING IS A MAJOR CAUSE OF RETURN TO THE CLINIC and DELAYS IN PROCESSING.

The test is complete once all 24 pages have been recorded.

How many colored symbols do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no do you see? What do you see? Where are they?

Check here if no

AUDIOLOGY

DO NOT TEST WITH HEARING AIDS

Right Ear

Canal/external ear ☐ Normal ☐ Abnormal (if abnormal, describe) Tympanic/membrane:

☐ Normal

☐ Abnormal (if abnormal, describe)

Left Ear

Canal/external ear ☐ Normal ☐ Abnormal (if abnormal, describe) Tympanic/membrane:

☐ Normal

☐ Abnormal (if abnormal, describe)

I have verified the applicant is not wearing hearing aids: Yes ☐ No ☐

If results are inconsistent or have unusual findings, re-explain test and repeat.

Daily Calibration Method: ☐ Oscar (machine) ☐ Biological (person)

Yearly Calibration Date: __________

Frequency 500 Hz

1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz

Right Ear

Left Ear

BODY MEASUREMENTS

Examiner Complete This Section

Height: _________ inches (without shoes) Weight: _________ pounds (without shoes)

VITAL SIGNS

Examiner Complete This Section

ALL VITAL SIGN CHECKS MUST BE DONE PRIOR TO FITNESS TEST

Readings

Pulse

Blood Pressure

Initial Reading

Repeat Reading (only if indicated)

Repeat heart rate at least 15 minutes after initial reading if pulse is less than 40 or 100 or greater

Repeat blood pressure at least 15 minutes after initial reading if blood pressure is greater than 140 systolic or greater than 90 diastolic

Examiner printed name

Examiner Signature

Date

ORTHOPEDIC CLINICAL EVALUATION

Examiner Complete This Section. If tenderness or pain is present, check “abnormal.”

Check each item in appropriate column Normal Abnormal

Upper extremities Knees Shoulders Range of motion/flexibility Range of motion/flexibility Strength/Stability Strength/Stability Tenderness Tenderness Pain Pain Ankles Arms Range of motion/flexibility Strength/Stability Strength/Stability Tenderness Tenderness Deformity Pain Elbow Feet Range of motion/flexibility Range of motion/flexibility Strength/Stability Strength/Stability Tenderness Tenderness Pain Pain Wrist Spine, Other Musculoskeletal Range of motion/flexibility Upper Back/Neck Strength/Stability Range of motion/flexibility Tenderness Strength/Stability Pain Tenderness Hand/Fingers Pain Range of motion/flexibility Mid Back Strength/Stability Range of motion/flexibility Tenderness Strength/Stability Pain Tenderness Lower Extremities Pain Hips Low Back Range of motion/flexibility Range of motion/flexibility Strength/Stability Strength/Stability Tenderness Tenderness Pain Pain Legs Strength/Stability Tenderness Deformity

****EXPLAIN ALL ABNORMAL ORTHOPEDIC FINDINGS FOUND ABOVE (USE ADDITIONAL PAGES IF NEEDED)

Last 4 SSN: DATE:

If ANY orthopedic injury or illness has occurred, document the following for each. Use additional paper if necessary.

Orthopedic Issue #1: Type of injury/illness (back strain, ankle sprain, carpal tunnel, etc.

How did the injury/illness occur?

Date of injury/diagnosis Describe treatment, including approximate dates Was surgery recommended? ☐ Yes ☐ No Was surgery performed? ☐ Yes ☐ No If yes: provide date; if no: provide rationale Did the candidate lose time from work/school? If so, when?

Have all symptoms resolved? ☐ Yes ☐ No If so, when?

If not, describe current symptoms, frequency, and when they occur.

Does the candidate report any current restrictions or limitations because of this issue? If so, describe.

Does the candidate report any residual symptoms with exercise (e.g., pain, swelling, exercise intolerance, etc.)?

Additional comments

Based on your physical exam, does the candidate appear to have limitations because of this issue? ☐ Yes ☐ No

Orthopedic Issue #2: Type of injury/illness (back strain, ankle sprain, carpal tunnel, etc.

How did the injury/illness occur?

Date of injury/diagnosis Describe treatment, including approximate dates Was surgery recommended? ☐ Yes ☐ No Was surgery performed? ☐ Yes ☐ No If yes: provide date; if no: provide rationale Did the candidate lose time from work/school? If so, when?

Have all symptoms resolved? ☐ Yes ☐ No If so, when?

Does the candidate report any current restrictions or limitations because of this issue? If so, describe.

Does the candidate report any residual symptoms with exercise (e.g., pain, swelling, exercise intolerance, etc.)?

Based on your physical exam, does the candidate appear to have limitations because of this issue? ☐ Yes ☐ No

If ANY orthopedic injury or illness has occurred, document the following for each. Use additional paper if necessary.

Orthopedic Issue #3: Type of injury/illness (back strain, ankle sprain, carpal tunnel, etc.

How did the injury/illness occur?

Date of injury/diagnosis Describe treatment, including approximate dates Was surgery recommended? ☐ Yes ☐ No Was surgery performed? ☐ Yes ☐ No If yes: provide date; if no: provide rationale Did the candidate lose time from work/school? If so, when?

Have all symptoms resolved? ☐ Yes ☐ No If so, when?

Does the candidate report any current restrictions or limitations because of this issue? If so, describe.

Does the candidate report any residual symptoms with exercise (e.g., pain, swelling, exercise intolerance, etc.)?

Based on your physical exam, does the candidate appear to have limitations because of this issue? ☐ Yes ☐ No

Orthopedic Issue #4: Type of injury/illness (back strain, ankle sprain, carpal tunnel, etc.

How did the injury/illness occur?

Date of injury/diagnosis Describe treatment, including approximate dates Was surgery recommended? ☐ Yes ☐ No Was surgery performed? ☐ Yes ☐ No If yes: provide date; if no: provide rationale Did the candidate lose time from work/school? If so, when?

Have all symptoms resolved? ☐ Yes ☐ No If so, when?

Does the candidate report any current restrictions or limitations because of this issue? If so, describe.

Does the candidate report any residual symptoms with exercise (e.g., pain, swelling, exercise intolerance, etc.)?

Based on your physical exam, does the candidate appear to have limitations because of this issue? ☐ Yes ☐ No

CLINICAL EVALUATION

Head, face, neck, and scalp (include thyroid)

Identifying body marks, scars, unique markings other than tattoos

Nose Skin, lymphatics Sinuses Neurologic Mouth and throat Deep tendon reflexes Ears – General, ear drums Balance Eyes – General, pupils, ocular, motility, nystagmus Strength

Heart (rhythm, sounds, murmur) ****NOTE ALL ABNORMAL FINDINGS BELOW Lungs and chest

Vascular system (Varicosities) Abdomen and viscera Hernia

PHYSICIAN/NP/PA SUMMARY OF SIGNIFICANT MEDICAL FINDINGS AND RECOMMENDATIONS

NOTES: Describe every abnormality if not already described on previous page(s). Describe in detail, based on history, and exam. Use additional sheets if necessary

I have reviewed and discussed the medical history with the candidate.

NAME OF EXAMINING PHYSICIAN/NP/PA: (Please print or type.) ☐ MD ☐ DO ☐ NP ☐ PA

PHYSICIAN/NP/PA SIGNATURE: