Physical Exam Form

2

05/17/07

A ttachment 15

Physical Exam Form

Physical Exam Form

Affix Case ID Label Here

Please indicate the month, day, and year in which the physical exam was conducted.

DATE: / /

Month Day Year

*ABTID:__ __ __ __ __ __ __ __ DATE: ____/____/____

Section 1: Vital Measurments STAFF ID:__ __ __
Blood pressure (mmHg)	Heart Rate	Respiratory Rate
/ systolic diastolic	 beats/min	 breaths/min
*Basal Temperature: .F *Weight:  lbs. *Height:  ft. in. *Neck Circumference: cm. *Waist Circumference: cm. *Hip Circumference: cm.

1. On a scale of 1 to 10 how well do you feel today?

1…….2…….3…….4…….5…….6…….7…….8…….9…….10

Not well at all Very well

2. On a scale of 1 to 10, how tired do you feel today?

1…….2…….3…….4…….5…….6…….7…….8…….9…….10

Not tired at all Extremely tired

Section 5: Physical Examination STAFF ID:__ __ __
	System	Not Done	Normal	Abnormal	If abnormal, explain or describe below:
1	Oral			
2	Head and Neck			
3	EENT			
4	Thyroid			
5	Chest			
6	Heart			
7	Lungs			

Section 5: Physical Examination (cont’d, part 2) STAFF ID:__ __ __
8	Abdomen			
9	Liver			
10	Spleen			
11	Extremities			
12	Skin			
13	Neurological			
14	Pulses			
15	Lymph nodes			
16	Joints and muscles			
17	Mental status			

Section 5: Physical Examination (cont’d, part 3) STAFF ID:__ __ __
18	Other (specify): _____________			
19	Other (specify): _____________			
20	Other (specify): _____________			

Impression: Please give a summary description of your overall impression of this patient

[mental status ,physical condition, over - or underweight, age corresponding to calendar or not, systems with problems, etc.

If you find anything abnormal -what differential diagnoses would you pursue should this be your (not a study) patient]

Section 6: Eligibility STAFF ID:__ __ __

*Eligible for Study: YES NO

*If not, Why?______________________________________________________________________

________________________________________________________________________________

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Signature

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