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Pre Employment Physical Form Template

Streamline your hiring process with a comprehensive pre-employment physical form

Collecting essential medical information from candidates can feel overwhelming, but it doesn't have to be. This pre-employment physical form template is designed to help HR professionals and hiring managers gather crucial health assessments for potential employees, ensuring they meet job requirements. With it, you can streamline the onboarding process, improve compliance with health regulations, and ensure new hires are fit for their roles, all while keeping the information well-organized and secure. You can explore this user-friendly template-ready to adapt to your needs.

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Full legal name
Date of birth
Email
Phone
Home address
Job title applied for
Department or worksite
Anticipated start date
Usual shift for this role
Day
Evening
Night
Rotating
Variable/On-call
Not sure
Emergency contact full name
Relationship to you
Emergency contact phone
Have you previously worked in this type of job?
Yes
No
Describe any prior work-related injuries or illnesses (if none, write 'None')
Are you able to perform the essential job functions with or without reasonable accommodation?
Yes, without accommodation
Yes, with accommodation
No
Not sure
Do you currently have any injury or pain that may affect your work?
Yes
No
Describe any current injury or pain (location, severity, limitations)
Which job tasks will this role require you to perform? Select all that apply.
Have you ever been diagnosed or treated for any of the following? Select all that apply.
Surgeries or hospitalizations in the past 5 years?
Yes
No
Provide details of recent surgeries or hospitalizations (dates, reasons, outcomes)
Do you take any prescription or over-the-counter medications or supplements?
Yes
No
List current medications and dosages (include over-the-counter and supplements)
Do you have any allergies?
No known allergies
Medications
Latex
Foods
Environmental (e.g., pollen, dust)
Insect stings
Prefer not to say
Other
Please Specify:
Describe allergy triggers and reactions (e.g., rash, swelling, anaphylaxis)
Tobacco or nicotine use
Never
Former
Current occasional
Current daily
Prefer not to say
Alcohol use
Never
Rarely
Sometimes
Often
Always
Prefer not to say
Recreational drug use in the past 12 months
Never
Past use, not current
Occasional
Regular
Prefer not to say
Do you use corrective lenses for vision?
Yes
No
Do you use a hearing aid?
Yes
No
Can you distinguish red, green, and yellow colors?
Yes
No
Not sure
Tetanus (Td/Tdap) booster within the past 10 years
Yes
No
Not sure
Hepatitis B vaccination series completed
Yes
No
Not sure
Tuberculosis (TB) test within the past year
Yes - negative
Yes - positive
No
Not sure
COVID-19 vaccination status
Fully vaccinated
Partially vaccinated
Not vaccinated
Prefer not to say
Have you ever been fit-tested for a respirator?
Yes
No
Not sure
Height (with units)
Weight (with units)
Blood pressure
Pulse
Physical exam notable findings
Drug screen collected today?
Yes
No
Not applicable
Fitness for duty determination
Medically qualified for full duty
Medically qualified with restrictions
Temporarily not qualified - re-evaluation required
Permanently not qualified
Deferred - additional information required
Work restrictions or accommodations (if any)
Recommended follow-up timeframe or tests
Examiner full name
Examiner license or credential
Clinic or organization name
Clinic phone
Date of examination
Follow-up or additional testing required?
Yes
No
I consent to allow the healthcare provider to release my fitness-for-duty determination to the employer listed on this form.
Yes
No
Applicant printed name (serves as signature)
Applicant signature date
I affirm that the information I have provided is true and complete to the best of my knowledge.
Yes
No
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Paper art illustration depicting a pre-employment physical form template for FormCreatorAI article

When to use this form

Use this form when you need to confirm a candidate can safely perform essential job tasks before finalizing an offer. It is valuable for roles that involve lifting, operating vehicles or machinery, healthcare duties, or public safety. HR and hiring managers get a clear, documented fitness decision; candidates get a fair review and guidance on any needed accommodations. For baseline checks like vitals and risk factors, pair it with the Health screening form. To gather job-related medical history that informs placement, add the Employee physical examination questionnaire form. If the role has exposure risks or shift work, include the Medical questionnaire form to note conditions that may require adjustments. The result: safer hires and fewer early injuries.

Must Ask Pre Employment Physical Questions

  1. Can you perform the essential functions of this job with or without reasonable accommodation?

    This confirms fitness for duty and guides whether you need accommodations to succeed. It keeps the focus on job tasks rather than diagnoses, reducing bias and improving lawful hiring decisions.

  2. Do you have any current work restrictions or limitations advised by a licensed clinician?

    Stating restrictions helps you place the hire safely and plan onboarding. It also documents guidance you can share with supervisors to prevent avoidable injuries.

  3. Are you taking any medications that may affect alertness, coordination, heat tolerance, or other job-related abilities?

    This identifies safety risks in driving, operating equipment, working at heights, or night shifts. You can then adjust duties or schedules to maintain safety without asking for unrelated medical details.

  4. Have you had any injuries, surgeries, or hospitalizations in the past 12 months that could impact job duties?

    Recent events can signal temporary limits or follow-up care that affects scheduling. For rehires returning from leave, align next steps with the Return to work discussion form.

  5. Are your role-specific immunizations and screenings up to date, or do you need testing (for example, TB, Hep B, vision, or hearing)?

    Confirming this now speeds onboarding for healthcare, food service, and safety-sensitive roles. It reduces start delays and ensures you meet policy requirements before day one.

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