Exhibit_D_-_Medical_Examination_Form.pdf
PDF 143 KB Posted
- Attached to
- Medical Services
- Solicitation number
- 2023-008Q
- Issued by
- Hidalgo County, Texas
About this file
The document is a Medical Examination Report form from the City of Edinburg Human Resources Department/Civil Service, designed for medical professionals to complete comprehensive physical examinations for potential employees. The form is specifically intended to assess the physical fitness of candidates, likely for critical public safety roles such as firefighters, police officers, and telecommunications personnel. The form requires detailed medical information including vision, hearing, vital signs, and overall physical condition, with space for the physician to recommend the candidate's fitness for work.
The medical examination form provides a structured approach for evaluating candidate health, with sections to document uncorrected and corrected vision, hearing capabilities, pulse rate, blood pressure, and assessments of various body systems. The physician is asked to make a final recommendation categorizing the candidate as physically fit (with no reservations), fit for limited work, or unfit, with options to explain any limitations. The form is to be returned to the City of Edinburg Human Resources Department, located in Texas, and can be submitted by calling the provided contact number (956) 388-1873.
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Text version
MEDICAL EXAMINATION REPORT
TO THE PHYSICIAN: The attached Health History should be completed by the person whose name appears below. You are required to complete the entire report.
LAST 4 SOCIAL SECURITY # XXX-XX- ___________ Date of Birth: _________________________________
NAME: ___________________________________________ _________ ___________________________________ _________ Last Suffix First Middle Initial
ADDRESS: ___________________________________________ _____________________________ ______ ______________ City ST Zip Code
TYPE OF APPOINTMENT: _____________________________________________________________
DATE OF MEDICAL EXAMINATION: __________________________________
1. HEIGHT: _______________________________ WEIGHT: _________________________
2. VISION: Uncorrected Corrected Right 20 / ______________ Right 20 / ______________ Glasses Left 20 / ______________ Left 20 / ______________ Both 20 / ______________ Both 20 / ______________ Contact Lenses
3. HEARING: (Ordinary conversation at 20 feet considered normal)
Right: ____________________________________________________ 20 / _________ Hearing Aide Used No
Left:______________________________________________________20 / _________ Yes
4. HEAD (Eyes, Ears, Nose, Mouth, Throat) ____________________________________________________________
5. (A) PULSE RATE: ____________________ (B) BLOOD PRESSURE: ______________________________________
6. LUNGS: 7. HEART (and Circulatory system)
8. ABDOMEN, G-I TRACT, HERNIA: 9. NERVOUS SYSTEM:
10. RECTAL: Fissure? Fistula? Hemorrhoids? 11.GENITO-URINARY: ___________
12. URINALYSIS: SP. Gravity __________________ Albumin __________________ Sugar __________________
13. SPINE: 14. EXTREMITIES: 15. SKIN: 16. VARICOSE VEINS (severity) ________
17. RECOMMENDATION AND COMMENTS: Candidate Is Physically
Fit (no reservations)
Fit for limited work (please comment on any limitations)
Unfit (please comment)
If limitations or unfit, please explain limitations and the expected duration: ______________________________________
SIGNATURE OF PHYSICIAN: DATE:
NAME AND ADDRESS OF PHYSICIAN (Please Print):
Phone:
Please Return Form To: City of Edinburg Human Resources Dept./Civil Service. Please Call (956) 388-1873.
Exhibit D
File details come from the government source that posted it. Updated .