Appx F_Physcal Examination (M/FF/CW)

Appendix F

PHYSICAL EXAMINATION

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

UNIQUE ID:

DATE:

blood pressure

Blood Pressure (arm: right / left ) _____________/______________

pulse

Pulse __________________________ bpm ( regular / irregular )

lungs

	CTAP
	Equal Excursions
	No Chest Tenderness

cor

	S1 S2 Appreciated
	No Rubs, Clicks, Murmurs or Gallops
	Regular Rhythm
	Pulses Palpable, Equal, Symmetrical
height & weight
Height		________________feet	____________________inches
Weight		__________________________ pounds

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

overall results

	Normal Exam (Physician’s Signature Below)
	Abnormal Exam (Explain Below)
(Physician’s Signature Below)