Document gaGRGd9y31Mrr5eZ3N7pNDE7J

INSTRUCTIONS FOR USE OF THIS EXAMINATION FORM ZA 1957 (Green) FOR THE EMPLOYER Examination blanks should be made up for each employee or new applicant on the typewriter in the office of the employer, making an original and two carbon copies. The first ten questions should be answered. These three blanks should be sent to the doctor as his authority for making the examination. The remaining questions on the blank should be answered on the typewriter in the doctor's office and he should send the original to us, one carbon to the employer, and keep one copy for his own record. Do not send us reports of applicants who are not hired. FOR THE EXAMINING PHYSICIAN 1. A typewritten original and two carbon copies, with the first ten questions answered, will be sent you by the employer. Please have the remaining questions answered and typewritten in your office, sending us the original, one carbon to the employer and keep one copy for your own record. Do riot send us reports of applicants who arc not hired. 2. If you wish to use one of the forms sent you by the employer as your work sheet in making your examination, please use one of the carbons, and make your original report on the original sent you by the employer. 3. Every question must be answered. 4. Use the words "Yes" or "No" where indicated. Do not use a dash, check mark, zero, or other character. 5. Record vision without glasses in every case, using Snellen method in feet. If glasses are worn, record vision both without and with them. 6. If heart murmurs are present, state area and time in the cardiac cycle in which they are heard, and whether function or organic. 7. Make urinalysis in every case, answering each of the four tests requested. If patient cannot furnish specimen, have him return when he can do so. 8. Indicate definitely whether X-Rays are required (Line 27). If applicant is referred for X-Rays, send your report to Radiologist in a sealed envelope. 9. Special attention should be paid to examination and answers in regards to hernia and varicose veins. 10. Note in report any definite loss of, or loss of use of, a member (fingers, hands, toes, feet, legs, eyes). Was compensation paid for such loss, or did such loss occur outside of employment? 11. Under last section, Line 38, give specific recommendations for any corrective treatment needed. 12. In order to bring out necessary lung detail, films should not be too dark. Exposure should be made in posterioanterior position, with lungs in full inspiration and individ ual holding his breath. The following technique has given uniformly good results. Current ICO milliamperes, distance 6 ft., exposure not longer than 1/10 second, leaving the kilovolt peak as the variable factor to accommodate for different types of chests. VPD-189-0002443