Form 1423 Polar Physical Exam

NATIONAL SCIENCE FOUNDATION

POLAR PHYSICAL EXAMINATION
Name: _______________________________________

Date of Birth: _______________

VITAL SIGNS

VISION

Height: _________

BP:______/______

Weight: _________

Pulse:___________
BMI: _____________

Finding

Blood Type: ________

Normal

Without Correction
DIST
R _______
L________

NEAR
_______
_______

Abnormal

General appearance

With Correction
DIST
R _______
L________

Finding

NEAR
_______
_______

Normal

Abnormal

Inguinal, include hernia

Head and neck

Genitalia

Eyes

Anal Rectum

Ears

Spine

Nose

Upper extremities

Mouth

Lower extremities

Thyroid

Skin (include body marks/tattoos)

Lymph nodes

Vascular

Chest and lungs

Neurologic

Breasts

Emotional Status

Heart

Pelvic exam

Abdomen

Prostate exam (age > 40)

Examiner – Please comment on all abnormal findings

Guiac Test (annually, age > 50): ____________________
Result/date
TB Skin test (annually) ____________________________

Influenza Immunization (annually) __________________
Date
Tetanus Immunization (every 10 years) ______________

Result/date

Date

Examiner – Please comment on overall fitness and health conditions that might interfere with the applicants ability to participate in a
remote polar deployment.

Examiner Name:______________________________________

Examiner Signature____________________________________

Examiner Street Address:______________________________

Office Phone: ________________________________

City: _______________________________ State: ________ Zip Code:_________________ Office Fax:_________________________
Please return the completed examination form and results of the requested tests to (return envelope enclosed)
(Contractor’s name and contact information will be inserted prior to mailing.)
NSF Form 1423 Page 1 of 1 (JAN 2011) Original plus one copy to: Contractor Medical Staff Applicants: Please retain one copy for your records
OMB CONTROL NUMBER 3145-0177: Expires