Workplace Health Forms

Patient Forms

• Registration Information Form – FOR ALL PATIENTS

Supplemental Patient Forms

• OSHA Respirator Medical Evaluation Questionnaire (English)
• OSHA Respirator Medical Evaluation Questionnaire (Spanish)
• Physical Health History Form – for non-DOT physical exams
• Occupational Health History Form – For non-DOT physical exams
• Workers Compensation Illness/Injury  – Initial visit medical history

DOT Medical Exam Supplemental Patient Forms

• CDL Medical Certification – DOT Medical Examination Report Form
• DOT Medical History Checklist
• DOT Driver Letters – Cardiovascular Disease
• DOT Driver Letters – Diabetes Mellitus
• DOT Driver Letters – Musculoskeletal Disorder
• DOT Driver Letters – Psychiatric Disorders
• DOT Driver Letters – Sleep Aide Medications
• DOT Driver Letters – Scheduled Drug Use
• MCSA-5895 – CMV Driver Medication Form
• MCSA-5870 – Insulin Treated Diabetes Mellitus Assessment Form
• MCSA-5871 – Vision Evaluation Report Form

Employer Forms

• Employer Authorization for Treatment Form
• Workers Compensation Insurance Information

Additional Resources

• Grand View Health Patient Portal
• Medical Release of Information Form
• Workplace Health and Wellness Sellersville Location Map

What To Bring With You

• Photo identification – all patients and adults who accompany patients under age 18 must have photo identification, such as a driver’s license, passport, military ID, employment badge or student ID card.
• Medical history information – bring information about past surgeries and medical conditions, allergies and current prescriptions.
• Insurance information – bring workers compensation insurance information, including name of insurer, policy number and claim number, for work-related injuries. We ask that patients also bring their insurance card as it may be requested if a referral to a specialist is needed.
• Any forms you have printed and completed in advance. These forms are also available for you to complete when you check in.
• Any forms you need the provider to complete, such as an employer-specific physical form.

Other Helpful Information

• Late arrivals – any patient arriving more than 10 minutes late for an appointment may be asked to reschedule.
• Treatment of minors – a parent or guardian must accompany the minor to all appointments.
• Patients are asked to not bring children with them to their appointment – due to the nature of certain services, for example drug testing and other diagnostic testing, only patients and staff are allowed in the testing and treatment areas. Children cannot be left unattended in the waiting room and the staff at Workplace Health & Wellness is not responsible for their supervision. Patients who bring children to an appointment may be asked to reschedule.