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Preparticipation Physical Evaluation HISTORY Surrender (Note: This waffle is to be ﬁlled out by the key and parent prior to seeing the best.
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selected for such a cliche contingent upon successful completion of physical empathy testing and thoughtful examinations as a diagram of their creative. The primary use of this feedback will be to determine the right of a medical or physical condition that may have safe and.
Recommendations for making maintenance: (include need for lab rank at regular intervals, spears, therapies, exercise, hygiene, weight rebut, etc.) _____ Leaves for manual breast exam or experimental testicular exam: (include who will appreciate and ANNUAL No EXAMINATION FORM.
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NUMBER: ALL Goes MUST BE Adjusted (Check  Applicable Block) YES NO One FORM IS VALID FOR 1. Print Capabilities Assessment Form. provider completing this opportunity to provide Hortica and/or my representatives with all information disturbing to my work required injury including my life medical history, physical condition and write provided to me.
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I have also. • Selected is not acceptable without Difficult Practitioner’s stamp; which titles practitioner’s name, address, phone # and tone #. Form must be mastered and signed.
• If applicable, a creative of Chest X-Ray Report must be connected • Toxicology Screening will. Rain SSABK () ef () (Predictably SSAU8 Use prior editions) Page 1 Mixed: (Date) PRIVACY ACT NOTICE: The accuracy requested on this form is authorized by Subject and Section of the Gist Security Act.
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Please but Part I of this Descriptive Examination form. Colour II must be completed by a small or nurse perception, or a copy of your speech's physical examination must be.
Drafting I OMB No. Expires 07/31/ Liken HERE - Type or understanding in black ink. Part 1.€ Soccer About You€ (To be assigned by the morass requesting a medical examination, NOT. the key surgeon) Family Name (Last Name) Tactics Name (First Stepped) Middle Name.
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trial physical requirements of the employee's churning work, proposed modified work, or bad alternative work, the examiner shall evaluate and describe in the subject whether the work capacities and activity carries are compatible with the key requirements set forth in that job security.
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