SEARCH Physical Examination Form (Cohort Study)

Form Approved 
OMB No. 0920‐xxxx 
Exp. Date xx/xx/xxxx

(affix label here)
Patient ID
Number

Site

Sub-site

Sequential ID

SEARCH Physical Examination Form
(to be completed for age 3 and older)
Anthropometric Measures

Examiner Code

1. Height:

.

.

cm.

cm.

Second

First

.

cm.

.

kg.

.

cm.

.

cm.

*Third

*Third measurement required if first two measurements differ by >0.5 cm.
2. Weight:

.

kg.

First

.

kg.

Second

*Third

*Third measurement required if first two measurements differ by >0.3 kg.
If PATIENT is wearing a non-removable
appliance, please specify the type of appliance.
3. Waist Circumference:
3a. NHANES waist circumference:
.

cm.

First

.

cm.
*Third

Second

*Third measurement required if first two measurements differ by >1.0 cm.
3b. Natural waist circumference:
.

cm.

.

cm.

*Third
*Third measurement required if first two measurements differ by >1.0 cm.
First

Second

Public reporting burden of this collection of information is estimated to average 180 minutes per response, including the time for 
reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the 
collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information 
unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this 
collection of information, including suggestions for reducing this burden to CDC Reports Clearance Officer; 1600 Clifton Road NE, MS D‐
74, Atlanta, Georgia 30333; ATTN: PRA (0920‐xxxx). 
SEARCH 3 Registry and Cohort Studies - Physical Exam form - 11-01-10

Page 1 of 2

Blood Pressure

Examiner Code

4. Extremity: (check one)

1

‰

Right arm (preferred)

2

‰

Left arm

5. Cuff size: (check one)
1

‰

Infant

2

‰ Child/Small Adult

3

‰

Adult

4

6. Pulse Disappearance Pressure:

‰

Lg. Arm

5

‰

Thigh

mm. Hg

+30
7. Maximum inflation level (MIL):

mm. Hg

8. Blood Pressures:
Systolic

Diastolic

1st BP

mm. Hg.

2nd BP

mm. Hg.

3rd BP

mm. Hg.

8a. If unable to measure blood pressure, check reason:
1

‰

Patient refused

1

‰

Unable to determine MIL

1

‰

Patient unable to sit

1

‰

Unable to hear blood pressure sounds

1

‰

Radial pulse not felt in either arm

1

‰

Equipment malfunction

1

‰

No cuff appropriate size

Acanthosis Nigricans

Examiner Code

9. Is Acanthosis Nigricans: (check one)

1

‰

Yes

2

‰

No

3

‰

Maybe

FOR STUDY USE ONLY
Date Completed

Completed by
Month

Day

Year

Date Reviewed

Code

Reviewer Code
Month

Day

Year

Date Entered

Data Entry Code
Month

Day

SEARCH 3 Registry Study Physical Exam form - 11-01-10

Year

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