Three Rivers Medical Clinic
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Three Rivers Medical Clinic
Wellness Forms

Adult Wellness Form
Sports Physical Form

DOT Physical: Federal Medical Examination Form
DOT Physical: Montana CDL Certification Form

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

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

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

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
Three Rivers Medical Clinic
16 Railway Avenue
PO Box 1078
Three Forks, Montana 59752
P: (406) 285-3251
F: (406) 285-6742

​frontdesk@threeriversmedicalclinic.net
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