As a caregiver with Kupuna Life, ensuring your health is essential—not just for you, but for the well-being and safety of our clients. One of the requirements for employment and ongoing care responsibilities is completing the Employee Physical Exam Form.

Why Is the Physical Exam Important?

Caregivers play a vital role in providing in-home services to Hawai‘i’s kūpuna. This physical exam helps ensure that caregivers are physically capable and free of any infectious conditions that could put clients at risk. It also confirms that you can safely handle the responsibilities of caregiving.

What Does the Physical Exam Include?

The form is completed by a licensed medical professional and covers the following sections:

1. Medical History
You’ll be asked to disclose whether you have experienced the following:

• Hospitalizations in the past 5 years
• Chronic illnesses
• Infectious diseases
• Musculoskeletal or neurological conditions
• Allergies
• Current medications

Be honest and thorough when providing this information—it’s for everyone’s safety.

2. Physical Examination Results
Your physician will record important health indicators, including:

• Height and weight
• Blood pressure and pulse
• Vision and hearing
• Cardiovascular, respiratory, musculoskeletal, neurological, and skin health

3. Immunizations and Tests
You’ll need up-to-date results for:

• Tuberculosis (TB) Test
• Hepatitis B Vaccination
• Influenza (Flu) Shot
• Tetanus Vaccination

If you’ve tested positive for TB in the past, a chest X-ray result must be provided.

4. Health & Safety Assessment
Finally, your doctor will assess if you have any infectious diseases or conditions that may pose a risk to clients, and confirm whether you’re physically and emotionally fit to provide care.

Who Fills It Out?

Only a licensed physician, clinic, or hospital staff can complete and sign the form. Make sure all sections are filled out and that signatures and dates are included.

Where to Submit

Once completed, submit the physical form to Kupuna Life’s administrative office or your designated contact person.

Final Note

This form isn’t just paperwork—it’s part of our shared responsibility to ensure a safe, compassionate, and healthy care environment. Mahalo for your cooperation and for being a part of the Kupuna Life ‘ohana!