OCCUPATIONAL HEALTH VISIT ASSESSMENT
Name
Reason for Visit
Date/Time
DOH
Dept.
Assessment:
ID#
Supervisor
Allergies
☐ Initial Visit
☐ Property Damage
☐ Work Related
☐ Follow Up
☐ RTW
☐ Non- Occupational Visit
Assess for alert, orient, lethargic, dizzy, SOA, pain, swelling, deformity, discoloration, crepitation, weakness, paresthesia, limitation
of motion- note any difference between affected side and unaffected side, local tenderness, contusion, abrasion, laceration,
hematoma with trauma, rash, drainage, bleeding, burn.
BP
HR
O2
Blood Sugar
Temp
Reason for Visit
Treatment Provided:
☐ Band-Aid
☐ Finger Cot/Splint
☐ Cohesive Wrap
☐ Steri-Strips
☐ Non-Adherent Pad
☐ TAO
☐ Oxygen
☐ Bio-Freeze
☐ Orajel
☐ Sting Kill
☐ Burn Jel
☐ Bacitracin
☐ Glucose
☐ Eye Wash
☐ Refresh Tears
☐ Elastic Bandage
☐ Stretch Gauze
☐ Hydrocortisone Cream
☐ Claritin
☐ Back Pain Off x 2 po q 6 hrs PRN
☐ Tyl 325 mg x 2 po
☐ IBU 200 mg x 2 po
☐ Aleve 220 mg x 2 po
☐ Wax Therapy
☐ Cold/Heat Pack x 20 minutes 4 times a day (Can start heat TX for muscle strains only after 24-48 hours)
Education Given:
☐ Heat / Ice Therapy Info
☐ Stretching PKT
☐ Proper Body Mechanics
☐ Job Rotation
OCCUPATIONAL HEALTH VISIT ASSESSMENT
Head-to-Toe Assessment
Date
Assessment Completed By
Time
LOC
☐Alert ☐Drowsy ☐Lethargic ☐Stuporous ☐Coma
Orientation
☐ Person
☐ Place
☐ Time
☐ Situation
Head
☐ Hair
☐ PERRLA
☐ Nose
☐ Ears
☐ Mouth
☐ Midline Tongue
☐ Moist
☐ Lesions
☐ Dentition
Neck
☐ Carotid Pulse
☐ JVD + ☐ Trachea Midline
Chest
☐ Apical Pulse
☐ Muffled ☐ Arrhythmia
☐ Breath Sounds- Anterior
☐ Posterior
☐ Lateral
☐ Chest Symmetry
☐ Skin Turgor (Clavicle)
Abdomen
☐ Inspection
☐ Auscultation
Active Hyper
Absent
☐ LUQ
Active Hyper
Absent
☐ RUQ
Active Hyper
Absent
☐ LLQ
Active Hyper
Absent
☐ RLQ
☐ Palpation
Upper Extremities
☐ Radial Pulse = +2
☐ Other
Warm
Cool
☐ Temp vs Trunk
☐ Grip equal and strong
☐ Capillary refill <3 sec
☐ Vein filling rapid
OCCUPATIONAL HEALTH VISIT ASSESSMENT
Lower Extremities
☐ Hair Present
☐ Edema
☐ Foot Strength
+/Claudication
☐ Homain’s
Warm
☐ Temp vs Trunk
☐ Nails ☐ Yellowed ☐ Thickened
☐ Pedal Pulse
ROM
☐ Upper R
☐ Upper L
☐ Lower R
☐ Lower L
☐ Sensation
R Palp / doppler
+/Cool
☐ Ingrown
L Palp / doppler
Strength
☐ Upper R
☐ Upper L
☐ Lower R
☐ Lower L
General Assessment
☐ Weight
☐ Height
☐ BM
Pain Assessment
What symptoms are the employee experiencing?
Onset: when did the symptoms start?
Location: What body part/s are effected?
Do the joints above/below the part have
symptoms?
Does the pain or symptoms radiate? If so, where?
Character: type of pain (dull, stabbing, aching, etc)
Alleviating factors: does anything reduce or
eliminate pain? Make the pain worse?
Temporal Patterns: do symptoms have a set
pattern, such as occurring every evening?
Have you injured this body part before?
Do you have any medical issues?
Rating of pain on scale of 1-10
Is there swelling, discoloration, deformity?
(describe)
Can the employee demonstrate ROM? Describe
movements demonstrated
Are pulses at or near the body part palpable?
Is there bleeding or other drainage of the body
part? (describe)
☐ Acute / Chronic
☐ Location
☐ Duration
☐ Characteristics
☐ Precipitation
☐ Frequency
☐ Non-Verbal
☐ Relief Factors
☐ Sleep
Skin Assessment
☐ Description
☐ Intensity 0-10
OCCUPATIONAL HEALTH VISIT ASSESSMENT
Is the skin compromised? (laceration, abrasion,
etc) Describe (measure)
Any other objective findings? (popping, crepitus)
What protocol applies?
Treatments provided: include time length (cold
compress x 10 minutes, dose, time, and next dose
of any medications given.
How often should problem be reassessed/treated?
Advisements: (include how often to f/u, when to
refer, etc)
Outcome of visit: (to ER, RTW, home, etc)
Any other information to include: