Physical Examination Form

Privacy Act Statement
The information you are being asked to provide is authorized to be
collected under Section 301 of The Public Health Service Act (42 USC
241). Providing this information is voluntary. CDC will use this
information in its study, SEARCH for Diabetes in Youth, in order to: (1)
Assess the incidence and prevalence of diabetes among youth in the U.S.
by diabetes type, and by demographics including age, sex, and race/
ethnicity; and (2) Assess temporal trends in diabetes incidence in major
US racial/ethnic groups, including African Americans, Hispanics, American
Indian Tribes, Asian Americans, Pacific Islanders, by age, sex, and
diabetes type. This information will be shared with third party clinical
entities with whom CDC has entered into an Agreement to assist with
carrying out this Study.

Form Approved
OMB No. 0920-0904
Exp. Date 08/31/2017

(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.

.

cm.

.

kg.

.

cm.

.

cm.

*Third

Second

First

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

.

kg.

First

.

kg.
*Third

Second

*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 80 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 (0920-0904).
SEARCH 4 Registry Study - Physical Exam form - 11-01-10

Page 1 of 2

Blood Pressure

Examiner Code

4. Extremity: (check one)



1



Right arm (preferred)

Left arm

2

5. Cuff size: (check one)
1



 Child/Small Adult

Infant



2

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:



Patient refused

1



Patient unable to sit

1



Radial pulse not felt in either arm

1



No cuff appropriate size

1
1
1
1



Unable to determine MIL



Unable to hear blood pressure sounds



Equipment malfunction

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 4 Registry Study - Physical Exam form - 11-01-10

Year

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