Three Rivers Medical Clinic
Wellness Forms

Adult Wellness Form

Sports Physical Form

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DOT Physical: Federal Medical Examination Form

DOT Physical: Montana CDL Certification Form

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Please print and complete both Part A and Part B.

Infancy

0-11 Months

1 Month, Part A

1 Month, Part B

2 Months, Part A

2 Months, Part B

4 Months, Part A

4 Months, Part B

6 Months, Part A

6 Months, Part B

9 Months, Part A

9 Months, Part B

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Please print and complete both Part A and Part B.

Early Childhood

1-4 Years

12 Months, Part A

12 Months, Part B

15 Months, Part A

15 Months, Part B

18 Months, Part A

18 Months, Part B

2 Years, Part A

2 Years, Part B

2.5 Years, Part A

2.5 Years, Part B

3 Years, Part A

3 Years, Part B

4 Years, Part A

4 Years, Part B

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Please print and complete both Part A and Part B.

Middle Childhood

5-10 Years

5 Years, Part A

5 Years, Part B

6 Years, Part A

6 Years, Part B

7 Years, Part A

7 Years, Part B

8 Years, Part A

8 Years, Part B

9 Years, Part A

9 Years, Part B

10 Years, Part A

10 Years, Part B

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Please print and complete both Part A and Part B.

Adolescence

11-21 Years

11-14 Years, Part A

11-14 Years, Part B

15-17 Years, Part A

15-17 Years, Part B

18-21 Years, Part A

18-21 Years, Part B