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Includes vaccination and laboratory test tracking for rubella, measles/MMR, TB screening options such as PPD and Quantiferon (QFT), with documentation requirements and chest X-ray instructions when indicated. Provides structured TB risk questions and a comprehensive physical exam section covering vitals, general appearance, and major body systems, marking normal or abnormal findings with 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past medical history sections does the form collect?","Question",{"text":108,"@type":109},"It gathers whether there is no reported history and lists conditions such as anemia, asthma, anxiety, epilepsy, GERD/GI disorders, glaucoma, and multiple additional diseases, cancers, diabetes types, heart disease, hepatitis, hypertension, and more.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the form handle TB testing and documentation?",{"text":113,"@type":109},"It records TB-related labs and screening such as Quantiferon (QFT) and PPD (Step 1/Step 2), requires attachment of reports, and specifies that if PPD/QFT is positive, a chest X-ray must be documented as negative for active TB with the report attached.",{"name":115,"@type":106,"acceptedAnswer":116},"What does the physical exam section include?",{"text":117,"@type":109},"It includes vitals (blood pressure, pulse, respiration) and a normal/abnormal assessment with comments for general appearance and major systems including skin, head/eyes/ears/nose/mouth, neck, musculoskeletal/gait, genito-urinary, cardiac, abdomen, respiratory, neurologic, psychiatric, and other body 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□Varicella (Chicken Pox)\u003Cbr>□ Tuberculosis | | | |\n| Past Medical History: | □ None Reported | | | |\n| □ Anemia\u003Cbr>□ Asthma\u003Cbr>□ Anxiety | □ Epilepsy\u003Cbr>□ GERD/GI Disorder\u003Cbr>□ Glaucoma | □ Hyperthyroid\u003Cbr>□ Hypothyroid\u003Cbr>□ Kidney Disease | | □ Neuropathy\u003Cbr>□ Sickle Cell Trait or Disease\u003Cbr>□ Stroke/CVA/TIA |\n| □ Cancer\u003Cbr>□ Cataracts\u003Cbr>□ COPD or Lung Disease\u003Cbr>□ Diabetes Type I\u003Cbr>□ Diabetes Type II | □ Heart Disease\u003Cbr>□ Headaches\u003Cbr>□ Hepatitis (A, B, C?)\u003Cbr>□ High Blood Pressure\u003Cbr>□ Liver Disease\u003Cbr>□ Motor Vehicle Accident\u003Cbr>□ Musculoskeletal disorder\u003Cbr>□ Neck or lower back pain\u003Cbr>□ Injury: non-work\u003Cbr>□ Injury: work\u003Cbr>□ Other: \u003Cbr>______________________\u003Cbr>______________________\u003Cbr>□ Hypercholesterolemia (Lipid Disorder) | | | |\n| Past Surgical History: | □ None Reported | | | |\n| □ Appendectomy\u003Cbr>□ Breast reduction □ Cataract removal\u003Cbr>□ C-Section\u003Cbr>Date of last\u003Cbr>surgery: | □ Cholecystectomy\u003Cbr>□ Hemorrhoidectomy\u003Cbr>□ Hysterectomy\u003Cbr>□ Laminectomy\u003Cbr>Other Surgical Notes: | | □ Liposuction\u003Cbr>□ Lumpectomy\u003Cbr>□ Mastectomy\u003Cbr>□ Ovarian cystectomy | □ Salpingectomy\u003Cbr>□ Tonsillectomy\u003Cbr>□ Thyroidectomy\u003Cbr>□ Tubal Ligation |\n| Medications: | □ None Reported □ Use Reported: | | | |\n\n\n| Social History:\u003Cbr>Tobacco Use:\u003Cbr>Length of Tobacco Use:\u003Cbr>Alcohol Use\u003Cbr>Narcotic/Stimulant Use: | □ Denies present tobacco use\u003Cbr>□ N/A\u003Cbr>□ Denies use\u003Cbr>□ Denies use | □ Smoke several cigarettes per day\u003Cbr>□ 1-5 years\u003Cbr>□ Consumes alcohol socially\u003Cbr>□ Presently using prescribed narcotics | □ Smokes >1 pack/day □ Social Smoker\u003Cbr>□ 6-10 years □ >10 years\u003Cbr>□ Consumes □ Consumes alcohol alcohol on a daily occasionally basis\u003Cbr>□ Presently using prescribed stimulants |\n| --- | --- | --- | --- |\n\n| Test/Vaccination | Date | Immune | | | Non\u003Cbr>Immune | | | | Date | Negative | | | Positive | | |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Rubella | | | | | | | | Quantiferon Test (QFT) | | | | | | | |\n| Rubeola (Measles) | | | | | | | | PPD (Step 1) | | | | | | | |\n| MMR Vaccine (1st Dose) | | | | | | | | PPD (Step 2) | | | | | | | |\n| MMR Vaccine (2nd Dose) | | | | | | | | If PPD/QFT positive-Chest Xray (**must state‘negative for active TB’*) | | ** must attach report | | | | | |\n| ** All labs (vaccinations as required) MUST be performed and reports MUST be attached | | | | | | | | | | | | | | | |\n\n\n| | Yes\u003Cbr>Yes\u003Cbr>Yes\u003Cbr>Yes | | No Productive cough for more than 3 weeks\u003Cbr>No Coughing up blood\u003Cbr>No Unexplained weight loss\u003Cbr>No Chest pain | | Yes\u003Cbr>Yes\u003Cbr>Yes | | No Fever, chills or drenching night sweats for no known reason\u003Cbr>No Persistent shortness of breath No Unexplained fatigue for more that 3\u003Cbr>weeks |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Yes No Temporary or permanent residence (for >1 month) in a country with a high TB rate (i.e., any country other than Australia, Canada, New Zealand, the United States, and those in western or northern Europe)\u003Cbr> Yes No Have you had close contact with\u003Cbr>someone who has TB\u003Cbr> Yes No Do you have a history of TB, LTBI and treatment | | | | Yes No Current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone>15mg/day for >1 month) or other immunosuppressive medication\u003Cbr> Yes No Do you have documentation of prior TB tests, either a tuberculin skin test (TST) or an interferon-gamma release assay (IGRA) blood test and results | | | |\n\n\n| PHYSICAL EXAM\u003Cbr>Normal (NL) Abnormal (AB) | | | | | | | |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Vitals: B/P: Pulse: Resp: | | | | | | | |\n| | N","cbCaiaLuGVsG0ZYe","https://ap.wps.com/l/cbCaiaLuGVsG0ZYe","pdf",127624,"English","# Past Medical History\n# Past Surgical History\n# Medications\n# Social History\n# Test/Vaccination\n# Physical Exam","[{\"question\":\"What past medical history sections does the form collect?\",\"answer\":\"It gathers whether there is no reported history and lists conditions such as anemia, asthma, anxiety, epilepsy, GERD/GI disorders, glaucoma, and multiple additional diseases, cancers, diabetes types, heart disease, hepatitis, hypertension, and more.\"},{\"question\":\"How does the form handle TB testing and documentation?\",\"answer\":\"It records TB-related labs and screening such as Quantiferon (QFT) and PPD (Step 1/Step 2), requires attachment of reports, and specifies that if PPD/QFT is positive, a chest X-ray must be documented as negative for active TB with the report attached.\"},{\"question\":\"What does the physical exam section include?\",\"answer\":\"It includes vitals (blood pressure, pulse, respiration) and a normal/abnormal assessment with comments for general appearance and major systems including skin, head/eyes/ears/nose/mouth, neck, musculoskeletal/gait, genito-urinary, cardiac, abdomen, respiratory, neurologic, psychiatric, and other body systems.\"}]","External - PCP Physical Exam Form - Pre-Employment v2 - 09-30-2025 | PDF",1788439239]