• Pre-Employment Physical Form

• 
  
• Name
• Email
• Phone

  --
• Address

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• Birthdate
• Height
• Weight
• Primary Physician
• Email
• Phone

  --
• 
  

• ---

• 
  

• Medical Information

• How frequently do you:

  	1x/Week	2-3x/Week	5-7x/Week	Never
  Use tobacco
  Drink alcohol
  Use marijuana/drugs
  Exercise

• Please List Any Medical Conditions*
• Do you have any medical conditions which require special work considerations?
  Yes No

  Please list.
• Do you have any lifting, standing, or sitting limitations?

  No Yes
• 
  
• Signature
• Date