Occupational Medicine Pre-Placement Medical History Form
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Occupational Medicine Pre-Placement Medical History Form
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This pre-placement medical history form is designed for occupational medicine providers, corporate health clinics, and employers conducting fitness-for-duty evaluations. The form systematically collects information about job requirements, physical demands, potential workplace exposures, and employee health status to determine medical suitability for specific job roles. It addresses OSHA requirements and helps identify accommodations needed under ADA guidelines.
The template includes detailed sections for job description and physical demands, past work injuries and workers compensation claims, exposure history to hazardous materials, respiratory and musculoskeletal screening, and medical clearance for safety-sensitive positions. This comprehensive approach helps occupational medicine providers assess whether candidates can safely perform essential job functions, identify potential workplace hazards, and establish baseline health data for ongoing occupational health surveillance programs.
What's included
- Job title and physical demands assessment
- Examination type (pre-placement, transfer, return-to-work)
- Safety-sensitive position designation
- Previous work injury and workers comp history
- Hazardous exposure checklist (chemicals, noise, silica)
- Respiratory protection requirements
- Lifting, standing, and mobility requirements
- Medical conditions affecting job performance
- Current medications and restrictions
- Physician clearance and accommodation recommendations
Who uses this template
- Occupational medicine clinics
- Corporate health and wellness centers
- Industrial hygiene services
- Employee health departments
- Third-party medical review organizations
All form fields
10 fields across 3 pages. Customize any field after signing up.
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