EFTA01221208.pdf

PHYSICAL EXAMINATION FORM PAGE I 012 0.47E Of IXAMIVOION TO BE FILLED IN BY EXAMINING PHYSICIAN (Please pant) I Month/ toy !Yeas last I Shut%CURIE,' I I L I I I I I I I I DME Of BIRTH ( Month / Dry rem ) I I PHONE I IA' I I HOME AIDORESS CITY STATE HEALTH HISTORY YES NO YES NO YES NO O 0 Asthma O 0 Muscular Disease O 0 Head or spinal injuries O 0 Kidney O 0 Psychiatric Disorder O 0 Seizures, fits, convulsions or fainting O 0 Tuberculosis O 0 Cardiovascular Disease O 0 Extensive confinement by illness or injury O 0 Diabetes ❑ 0 Gastrointestinal Ulcer O 0 Any other nervous disorder O 0 Nervous Stomach O 0 Ethanol use O 0 Suffering from any other disorder O 0 Rheumatic Fever O 0 Rx drug use O 0 Permanent defect from illness, disease or injury O 0 Over the counter drug use ANY Of THE MOW IS YES, IMAM. GENERAL APPEARANCE AND DEVELOPMENT: 0 Good 0 Fair 0 Poor VISION: For Distance: 0 Right/2O 0 Left/2O 0 Both/2O 0 Without Corrective Lenses ElWith Corrective Lenses Evidence of disease or injury: I Right I Left Color Test: Horizontal Field of Vision: I Right I I Left HEARING: I Right Ear I I Left ear Evidence of disease or injury: [Right I Left AUDIOMETRIC TEST: Decibel loss at 0500 HZ 0 1,000 Hz 0 2,000 Hz 0 3,000 Hz 0 4,000 Hz 0 5.000 Hz 0 6,000 Hz 0 7,000 Hz 0 8,OOO Hz THROAT: THORAX: Heart: If organic disease is present, is it fully compensated? Blood Pressure: I Systolic I 'Diastolic Pulse: 'Before Exercise 'Immediately after Lungs: ABDOMEN: Scars I Abdominal Masses I I Tenderness NMional Commission for the Colikation of Crane Opetators 0 7007 MC CR REV 0507 29 EFTA01221208 PHYSICAL EXAMINATION FORM ( ) PAGE 2 O12 HERNIA: ❑ Yes El No I If so, where? I Is truss worn? GASTROINTESTINAL: Ulceration or other disease? I Yes I No GENITO•URINARY: I Scars: I Urinal Discharge: REFLEXES: Rhomberg Pupillary: Light I R Accommodation: IR IL KNEE JERKS: Right INormal I lincreased I Absent Left INormal Ilncreased I Absent REMARKS: EXTREMITIES: I Upper I Lower I ISpine LABORATORY & I Urine Spec. Gr. lAlb I ISugar OTHER SPECIAL FINDINGS: Other Laboratory Data (Serology etc.) IRadiological Data I Electrocardiograph GENERAL COMMENTS: INAME Of fxA!u.\I\G DOCTORIPtEA1E PRAT) I SKAATURI IADDRESS 01 EXAMINING DOCTOR 'OTT MEDICAL EXAMINER'S CERTIFICATE TO BE COMPLETED ONLY IF OPERATOR IS FOUND QUALIFIED MEDICAL EXAMINER'S CERTIFICATE MEDICAL EXAMINER'S CERTIFICATE I certify that I have examined I certify that I have examined (MN( 04•00003 5 UM( (MN CRANE OPIRATOWS NAME (PRINT) with the knowledge of his/her duties, with the knowledge of his/her duties, I find him/her qualified under the regulations. I find him/her qualified under the regulations. ■ Qualified only when wearing corrective lenses. • Qualified only when wearing corrective lenses. ■ Qualified only when wearing a hearing aid. ❑ Qualified only when wearing a hearing aid. • Qualified — see Accommodation Statement attached. ■ Qualified — see Accommodation Statement attached. A complete examination form for this person is on file in my office: A complete examination form for this person is on file in my office: IADDRESS I ACOTUSS IWOE Of EMAINAINOV I i NAME Of EXAMINING DOCTOR I DATE Of EXAMINATION I I NAM Of EXAMINING DOCTOR ISIGMA E* Of EXAMINING DOCTOR I SIGNATURE Of EXAMENING DOCTOR ISIGNAMITI Of OPERATOR I SRAM ME Of OPERATOR IADDRESSOf OPERATOR I AOOR(SS Of OPERATOR 30 National Commission for the Certification of Crane Operators 02007 MC CH REV 05107 1 EFTA01221209