Well Check Program (Annual Physical Exam and Health Risk Assessment)

Employee Information
Physician Information
Submit

Employee Information
Physician Information

First Name

Mid Initial

Last Name

Employee ID

District/Division

Email Address

Are you currently filling this form out in the presence of your primary care physician?

Yes

NOTE: If you prefer to print this form and take it in with you, visit the HRD Wellness Program webpage – under the ‘Polices & Forms’ tab to print out a physical copy.

Step 1: Annual Physical Exam and Physician's Verification

I certify that the employee listed above has received a routine physical examination under my care.

Physician Name

Exam Date (MM/DD/YYYY)

Physician Signature

Form Title

Step 1: Annual Physical Exam and Physician's Verification