1. Georgia Department of Human Resources
PHYSICAL EXAMINATION
Applicant's/ Employee's Name: Date:
Height: Weight: DOB:
GENERAL APPEARANCE
Head: Breast:
Eyes: Axilla:
Ears: Lungs
Nose: Abdomen:
Mouth: Heart:
Throat: Pulse:
Neck: Blood Pressure:
Chest: Other:
EXTREMITIES
Deformities: Limited Motion:
Swelling of Joints: Edema:
Blood Vessels: Varicosities:
SKIN
Rash: Infected Areas:
Cuts or Bruises: Purpura:
Other:
URINALYSIS:
Normal: S.G.:
Albumin: Sugar:
TUBERCULIN SKIN TEST (Medical Provider or DPH):
If positive, x-ray of chest? If positive, medication prescribed?
cw564physicalexaminationoffsw-150714130525-lva1-app6892.docA Physical Examination of Family Service
Worker (Revised 09/06) Page 1 of 1