Physical Examination Format Pdf Form PDF Details

Are you preparing to take a physical examination or apply for a job and need an easy-to-use form? Physical Examination Format Pdf Form is the perfect tool to help you get organized. This comprehensive PDF document provides everything you need—an easy-to-follow format, clear instructions, and useful tips—so that no important information goes unrecorded during your physical evaluation. Whether this is your first time scheduling an exam or have taken many before, this user-friendly guide helps make sure all aspects of your appointment are properly documented. With Physical Examination Format Pdf Form as your go-to solution, nothing will be overlooked!

QuestionAnswer
Form NamePhysical Examination Format Pdf Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesPneumococcal, INH, sample physical assessment pdf, 2008

Form Preview Example

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL EXAMINATION FOR COLLINGSWOOD SCHOOLS

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Age:

 

DOB:

 

 

 

 

 

 

 

 

 

Gender:

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

 

Zip

 

 

 

Home Phone:

 

 

 

 

 

 

 

 

 

 

 

School:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Grade:

 

 

 

 

Physician:

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

Physician’s Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN OR PROVIDER INFORMATION – PLEASE COMPLETE BOTH SIDES

 

 

 

Exam Date:

 

 

 

 

 

Height:

 

Weight:

 

 

 

Blood Pressure:

 

 

 

/

 

 

 

 

Pulse:

 

 

bpm.

Vision: R 20/

L 20/

 

Corrected: Y / N

Contacts: Y

/ N Glasses: Y /

N

Hearing:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Normal

 

 

 

Abnormal Findings

 

 

 

 

 

 

 

 

Comments

 

 

 

Head/Neck

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eyes/Sclera/Pupils

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ears

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nose/Mouth/Throat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Murmurs/Rhythms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lungs:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Auscultation/Percussion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chest Contour

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abdomen:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assessment (inc. liver, spleen)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tanner Stage:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Testes/Onset of Menses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

Yes/Possible

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hernia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neck/Back/Spine:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Range of Motion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Scoliosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Upper Extremities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lower Extremities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neurological:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Balance & Coordination

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Romberg

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heel Walk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tandem Walk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nose Touch

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Toe Walk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Most recent immunizations/Dates:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medications currently in use:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Observations/Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 2/2008

 

 

 

 

 

 

 

 

Continued on back of page

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HISTORY: Please check all areas where diseases or alterations have occurred and explain below:

 

Allergies/Anaphylaxis

 

Eczema/Skin

 

 

Hospitalizations/Surgery

 

Asthma/Respiratory

 

Endocrine

 

 

Musculoskeletal

 

Cardiovascular/Murmur

 

Gastrointestinal

 

 

Neurological/Seizures

 

Childhood diseases

 

Genitourinary

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Explanation/comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLEARANCE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

Student may participate in physical education: Yes:

 

 

No:

 

 

Date:

 

 

B.

Cleared after completing evaluation for:

 

 

 

 

 

 

 

 

C.

NOT CLEARED FOR: Collision:

 

 

 

Contact:

 

 

 

Non-Contact:

 

 

 

 

 

 

Strenuous:

 

 

 

Moderate:

 

 

 

Non-Strenuous:

 

 

 

Diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recommendations:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Only this certificate is to be used to certify that a child has met the immunization requirement for attending school. Include immunizations given on this date. ALL DATES MUST INCLUDE DAY, MONTH AND YEAR.

VACCINE

TOTAL #

DATE

 

DATE

 

DATE

 

DATE

 

DATE

 

DOSES

 

 

 

 

 

 

 

 

 

 

DPT/DTaP

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Pediatric DT*

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

OPV

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

IPV

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

MMR

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Measles

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Mumps

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Rubella

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

HIB or Prohibit

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Varicella

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal (PCV7)

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Meningococcal

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

RSV

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Influenza

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

* Requires a physician’s written medical contraindication to further pertussis vaccine when given to children under age 7.

TUBERCULOSIS TESTING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mantoux tests:

Date:

 

Result:

 

 

 

 

Date:

 

 

 

Result:

 

Chest x-ray:

Date:

 

Result:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INH Therapy:

Date started:

 

 

 

 

 

Dosage:

 

 

 

 

How long:

 

EXAMINED BY: Physician’s/Provider’s Stamp:

Family Physician/Provider:

 

 

 

 

School Physician:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___ MD ___ DO ___ NP ___PA

Physician’s/Provider’s Signature

Date

Revised 2/2008

How to Edit Physical Examination Format Pdf Form Online for Free

Making use of the online PDF tool by FormsPal, you are able to fill in or edit foot physical exam right here and now. Our editor is constantly developing to grant the best user experience attainable, and that's because of our resolve for constant development and listening closely to customer feedback. It merely requires several simple steps:

Step 1: Hit the "Get Form" button above. It'll open our tool so you can begin completing your form.

Step 2: The tool allows you to customize PDF documents in various ways. Transform it with any text, adjust original content, and put in a signature - all possible within a few minutes!

When it comes to blanks of this particular document, here's what you should know:

1. When completing the foot physical exam, ensure to complete all necessary blanks within its relevant part. This will help hasten the work, allowing for your details to be handled promptly and accurately.

2008 conclusion process outlined (step 1)

2. Once your current task is complete, take the next step – fill out all of these fields - Exam Date Vision R HeadNeck, and YesPossible with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Part number 2 for filling out 2008

3. In this part, take a look at Exam Date Vision R HeadNeck, Revised, and Continued on back of page. Every one of these have to be completed with greatest focus on detail.

Continued on back of page, Exam Date Vision R  HeadNeck, and Revised of 2008

4. To move forward, the next stage involves completing several blank fields. These include HISTORY Please check all areas, AllergiesAnaphylaxis, EczemaSkin Endocrine, HospitalizationsSurgery, A Student may participate in, Contact Moderate, NonContact NonStrenuous, Only this certificate is to be, VACCINE, TOTAL DOSES, DATE, DATE, DATE, DATE, and DATE, which you'll find crucial to going forward with this particular PDF.

2008 conclusion process explained (step 4)

5. And finally, this final part is what you need to complete prior to using the document. The blanks here include the following: OPV, IPV, MMR, Measles, Mumps, Rubella, Hepatitis B, HIB or Prohibit, Varicella, Pneumococcal PCV, Meningococcal, RSV, and Influenza.

Step # 5 for filling out 2008

Be really careful when filling out Influenza and Pneumococcal PCV, since this is where a lot of people make some mistakes.

Step 3: Make sure that your details are right and just click "Done" to conclude the project. Try a free trial subscription at FormsPal and acquire immediate access to foot physical exam - with all adjustments preserved and accessible from your FormsPal account page. FormsPal provides secure document completion devoid of personal data recording or any type of sharing. Rest assured that your details are secure with us!