Forms

Important paperwork you will need to complete before your appointment with The Occupational Health Services at Chester County Hospital.

Patient Forms:

• OHC History: Occupational and medical history for new patients coming for physical exams
• OHC Interval History: Occupational and medical history for patients returning for periodic exams
• OHC Registration Form: Every patient must complete this form
• OSHA Respirator Clearance Questionnaire: For employees who need to wear a respirator for their job
• Injury/Illness Initial Visit Form: Completed at the time of the first appointment for a work-related injury/illness
• Authorization for the Use/Disclosure of Protected Health Information
• Travel Medicine Questionnaire

Department of Transportation Forms:

Important paperwork for employees who drive and operate vehicles.

• DOT Dear Driver Letter
• DOT Cardiovascular Pre Exam
• DOT Diabetes DM Pre Exam
• DOT Hearing Pre Exam
• DOT Hypertension HTN Pre Exam
• DOT Musculoskeletal Pre Exam
• DOT Obstructive Sleep Apnea Pre Exam
• DOT Psychiatric Pre Exam
• DOT Scheduled Drug Use Pre Exam
• DOT Seizure Pre Exam