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Medical Examination Report Form Template

Streamline your health assessments with an efficient form template

Completing a medical examination report can be daunting, especially when you're focused on compliance and accuracy. This template is designed for employers and healthcare professionals looking to simplify the process of gathering essential health information for new hires or current staff. With this form, you benefit from easy data collection, streamlined tracking of medical conditions, quick approvals for employee fitness, and better reporting for compliance standards-all while ensuring WCAG-aligned accessibility. Explore the template to see how it can make your workflow smoother.

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Full legal name
Date of birth
Phone number
Home address
Email address
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Date of examination
Facility or clinic name
Purpose of examination
Routine check
Pre-employment
School or sports
Insurance
Follow-up
Other
Please Specify:
Past or current medical conditions (select all that apply)
Please Specify:
Surgeries or hospitalizations (include dates if known)
Family history of major illness (select all that apply)
Heart disease
Stroke
Diabetes
Cancer
Hypertension
Mental health condition
None
Unknown
Other
Please Specify:
Pregnancy status (if applicable)
Pregnant
Not pregnant
Not applicable
Prefer not to say
Current medications (name, dose, frequency)
Do you have any known drug allergies?
Yes
No
Not sure
Allergy details and reactions
Any food or environmental allergies?
Yes
No
Not sure
Tobacco use
Never
Former
Occasionally
Daily
Prefer not to say
Alcohol use
Never
Former
Occasionally
Daily
Prefer not to say
Occupation
Recreational drug use
Never
Former
Occasionally
Daily
Prefer not to say
Primary concern or reason for visit
How long have you had this concern?
Less than 24 hours
1-7 days
1-4 weeks
1-3 months
Over 3 months
Not applicable
Review of systems (select all currently relevant)
Height (with units)
Weight (with units)
Blood pressure (mmHg)
Heart rate (bpm)
Temperature (with units)
Oxygen saturation (SpO2 %)
Objective findings and exam notes
Overall exam impression
Normal
Minor abnormalities
Significant abnormalities
Not examined
Assessment or diagnosis
Plan and recommendations
Follow-up required
None
As needed
In 1-2 weeks
In 1-3 months
Refer to specialist
Further testing needed
Work or school clearance
Cleared without restrictions
Cleared with restrictions
Not cleared
Not applicable
I consent to share this report with the named parties for care or administrative purposes
Yes
No
Patient full name (acknowledgment)
Patient acknowledgment date
Examiner full name
Examiner role or credentials
I attest that the information in this report is accurate to the best of my knowledge
Yes
No
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Paper art illustration depicting a medical examination report form for FormCreatorAI article.

When to use this form

Use this form when you need a clear, standardized summary of a person's health status and fitness for a specific task. It fits pre-employment screenings, annual occupational health checks, pre-surgery reviews, school or sports clearance, and insurance assessments. You capture history, vitals, exam findings, and recommendations in one place, so employers, HR, and care teams can act fast and document decisions. To gather prior records that inform your assessment, pair it with a Medical chart review form. If the role or setting requires infectious disease checks, add a TB Screening form. For procedures, coordinate with a Surgery clearance form to align perioperative requirements with current findings.

Must Ask Medical Examination Report Questions

  1. What is the purpose of the examination and the role or activity it supports?

    This defines the standard you must meet, such as safety for a job, school sports, or a procedure. Clear intent helps you tailor the scope and interpret results against the correct requirements.

  2. What are the person's key vital signs and current symptoms?

    Vitals and symptoms show the immediate risk level and baseline status. Abnormal values flag conditions that need urgent care or limit duties until addressed.

  3. Which medical conditions, surgeries, allergies, or medications could affect safety or performance?

    This surfaces contraindications, drug interactions, and stability of chronic disease. It also explains findings that might otherwise seem unrelated and supports risk counseling.

  4. What physical exam findings are relevant to the required tasks or environment?

    Document objective results (cardio-respiratory, musculoskeletal, vision, skin) that map to job or activity demands. This makes your recommendations defensible and reduces back-and-forth.

  5. What restrictions, accommodations, or follow-up do you recommend, and for how long?

    Actionable guidance helps employers and coordinators schedule duties, training, or reevaluation. For work cases, align your guidance with a Physician release to return to work form so HR can close the loop.

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