Free template
Pre-employment medical checkup form template
Template for general use. Some roles and states require specific statutory forms — consult the applicable state rules. Detailed medical findings should stay confidential; share only the fitness opinion with HR.
1. Candidate details
- Name: ____________________ Date of birth: __________
- Role offered: ____________________ Department: __________
- Employer: ____________________ Date: __________
2. Medical history (candidate to complete)
- Past illnesses / surgeries: ______________________________
- Current medicines: ______________________________
- Allergies: ______________________________
- Consent to examination and to share the fitness opinion with the employer: Yes / No Signature: ________
3. Examination
- Height ____ cm Weight ____ kg BMI ____ BP ____/____ Pulse ____
- Vision: distance ____ near ____ colour ____
- Hearing: ______ Chest: ______ Abdomen: ______ Musculoskeletal: ______
4. Tests (as per role)
- Test: ______________ Result: ______________
- Test: ______________ Result: ______________
- Test: ______________ Result: ______________
5. Fitness opinion
- [ ] Fit [ ] Fit with restrictions [ ] Temporarily unfit [ ] Refer for specialist review
- Restrictions / retest date: ______________________________
- Doctor's name, qualification and registration: ______________________________
- Signature and date: ______________________________
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