**Scroll down to see entire page**

VISIT FORMS - Prepare for your visit

​You may print forms and fill in by hand, or you can fill them in on your computer.  
If you don't have time or a printer, these forms will also be available in the clinic during your visit.
If you are applying for a job at Bridgestone and need a Pre-Employment Physical, please return to the Schedule Appointment page and select the tab titled 'Pre-Employment physical' for detailed instructions on how to get your ePassport (medical history)for your medical appointment. 
Visit Form:
Complete these two forms for all visits (initial or subsequent) except the Confined Space Exam or Pre-employment Exam.  It includes a quick review of your current medications, confirms your allergies, and asks you about what you will need on your visit.  Please be sure to complete the review of systems pages.  This provides important information about what's bugging you.  
visit_report.pdf
File Size: 509 kb
File Type: pdf
Download File
enc_ros.pdf
File Size: 224 kb
File Type: pdf
Download File
Health History:
Complete this form if this is your very first visit.  This form will be maintained, IAW HIPAA laws, in your Aiken Regional Medical Center Medical File and kept separately from your Bridgestone Health Record.  ​
Information is used to prepare for your visit and make your health care specific to you.  Bridgestone will not have access to this data.  
health_history_fill-in.pdf
File Size: 647 kb
File Type: pdf
Download File
Confined Space Pre-Training Physical Exam:  
Use these two forms for the confined space training physical only.  These forms will be maintained in your Bridgestone Health Record.  This is an OSHA requirement.  A copy will be given to you for your personal records.  These are not Aiken Regional Medical Center forms.  
**You do NOT need to complete the Visit Form or Health  History Form for the confined space training exam.**
914-113_respirator_and_medical_surveillance_evaluation_history.pdf
File Size: 206 kb
File Type: pdf
Download File
sc-ai-plt-m17041308420.pdf
File Size: 180 kb
File Type: pdf
Download File
Pre-Employment Physical Exams:
  • ​For more information on the Pre-Employment physical process, please return to the 'Schedule Appointment' page and select the tab titled, 'Pre-Employment Physical.'​
How to make an Adobe form fillable:
  • Download the document to your desk top.
  • Open the document.
  • From the top left corner, select the icon that looks like a piece of printed paper with a pen. (3rd from left).
  • When you hover over it, it should say, “sign, add text, or send document for signature.”
  • A light gray box will appear on the right side of the document titled, “I Need to Sign.” Click/select, ‘Add Text.’
  • Mouse over to block you want to fill in, click/select it, and begin typing. Use tab to get to the next box in the row or put your cursor at the beginning of the box.  Don’t worry, neatness does not count. 
  • To check a box, click on the ‘Add checkmark’ icon which is located below the ‘Add Text’ icon, then click over the box. To go back to adding text, click/select on the ‘Add Text’ icon again.  The icon you are currently using will turn a darker gray.
  • Complete the form, save it, print it, or email it to alumbaughilse@bfusa.com.  
  • Please be alert to the fact that your form will be emailed to BFUSA's Outlook email, NOT a secure email.   


We would love to assist you in your journey to wellness!