Free Pre-Employment Medical Examination Checklist Template
Medical Examination Checklist
|
Name |
Address |
Company |
|---|---|---|
|
[your name] |
[your company address] |
[your company name] |
Vital Signs Assessment
|
YES |
NO |
|
|
Blood Pressure Measurement |
|
|
|
Heart Rate Measurement |
|
|
|
Respiratory Rate Measurement |
|
|
|
Temperature Measurement |
|
|
Vision Testing
|
YES |
NO |
|
|
Visual Acuity Testing (e.g., Snellen chart) |
|
|
|
Color Vision Testing (e.g., Ishihara test) |
|
|
|
Peripheral Vision Testing (e.g., confrontation test) |
|
|
|
Depth Perception Testing |
|
|
Hearing Assessment
|
YES |
NO |
|
|
Audiometry Test |
|
|
|
Tympanometry Test |
|
|
|
Acoustic Reflex Test |
|
|
|
Speech Recognition Threshold Testing |
|
|
Medical History Review
|
YES |
NO |
|
|
Review of Personal Medical History |
|
|
|
Review of Family Medical History |
|
|
|
Review of Previous Surgical Procedures |
|
|
|
Review of Current Medications and Allergies |
|
|
Immunization Verification
|
YES |
NO |
|
|
Verification of Complete Immunization Records |
|
|
|
Verification of Vaccination Against Hepatitis B |
|
|
|
Verification of Influenza Vaccination |
|
|
|
Verification of Tetanus, Diphtheria, Pertussis (Tdap) Vaccination |
|
|
General Health Screening
|
YES |
NO |
|
|
Body Mass Index (BMI) Calculation |
|
|
|
Skin Examination for Abnormalities |
|
|
|
Abdominal Palpation |
|
|
|
Musculoskeletal Examination |
|
|
Laboratory Testing (if applicable)
|
YES |
NO |
|
|
Complete Blood Count (CBC) |
|
|
|
Lipid Profile |
|
|
|
Blood Glucose Level |
|
|
|
Urinalysis |
|
|
Mental Health Evaluation (Optional)
|
YES |
NO |
|
|
Screening for Depression (e.g., PHQ-9) |
|
|
|
Anxiety Disorder Screening (e.g., GAD-7) |
|
|
|
Cognitive Function Assessment |
|
|
