Standard Form 88 at a glance
What it is: Standard Form 88 (Rev. 10-94) is the Medical Record Report of Medical Examination.
Who signs: The physicians sign boxes 48 and 49, a dentist or physician signs box 50 (indicating which), and the reviewing officer or approving authority signs box 51.
A filled-in Standard Form 88 example: an examiner fills in the examinee's first page
How to fill out Standard Form 88, box by box
Date of Exam and boxes 1 to 9, name and home address
Enter the Date of Exam.
Enter Last Name - First Name - Middle in box 1.
Enter the Identification Number in box 2 and the Grade and Component or Position in box 3.
Enter the Home Address (Number, street or RFD, city or town, state and ZIP Code) in box 4 and the Emergency Contact (Name and address of contact) in box 5.
Enter the Date of Birth in box 6, the Age in box 7 and the Relationship of Contact in box 9.
Mark Female or Male for Sex in box 8.
Boxes 10 to 16, place of birth, race, agency and the examiner
Enter the Place of Birth in box 10.
For Race in box 11, mark White, Black, American Indian/ Alaska Native, Hispanic White, Hispanic Black or Asian/Pacific Islander.
Enter the Agency in box 12a, the Organization Unit in box 12b and, for Total Years Government Service in box 13, a. Military and b. Civilian.
Enter the Name of Examining Facility or Examiner, and Address in box 14 and the Rating or Specialty of Examiner in box 15.
Enter the Purpose of Examination in box 16.
17. Clinical Evaluation
In box 17 Clinical Evaluation, check each item in the appropriate column, Normal or Abnormal, and enter "NE" if not evaluated.
Under NOTES, describe every abnormality in detail, enter the pertinent item number before each comment, and continue in item 42 and use additional sheets if necessary.
The form prints "O. PROSTATE (Over 40 or clinically indicated)".
The form prints "CC. PELVIC (Females only)".
The form prints "G. EYES - GENERAL (Visual acuity and refraction under items 28, 29, and 36)", "B. EARS - GENERAL (INTERNAL CANALS) (Auditory acuity under items 39 and 40)" and "Z. NEUROLOGIC (Equilibrium tests under item 41)".
18. Dental
In box 18 Dental, place appropriate symbols, show in examples, above or below number of upper and lower teeth.
The examples show Restorable Teeth, Non-restorable Teeth, Missing Teeth, Replaced by Dentures and Fixed Partial Dentures.
Enter Remarks and Additional Dental Defects and Diseases.
19. Test Results
Copies of results are preferred as attachments for box 19 Test Results.
Under A. Urinalysis, enter (1) Specific Gravity, (2) Urine Albumin, (3) Urine Sugar and (4) Microscopic.
Enter the Place, date, film number and result for B. Chest X-ray or PPD.
Enter the test used and results for C. Syphilis Serology.
Enter D. EKG, E. Blood Type and HR Factor and F. Other Tests.
Boxes 20 to 27, measurements, blood pressure and pulse
Enter Height in box 20, Weight in box 21, Color Hair in box 22, Color Eyes in box 23, Build in box 24 and Temperature in box 25.
For Build, mark Slender, Medium, Heavy or Obese.
For Blood Pressure (Arm at heart level) in box 26, enter Sys. and Dias. for A. Sitting, B. Recumbent and C. Standing (5 mins.).
For Pulse (Arm at heart level) in box 27, enter A. Sitting, B. Recumbent, C. Standing (3mins.), D. After Exercise and E. 2 mins. After.
Boxes 28 to 38, vision and intraocular tension
Enter Distant Vision in box 28 as Right 20/ and Left 20/, with Corr. to 20/.
Enter Refraction in box 29, Near Vision in box 30 and Heterophoria in box 31 (Specify distance).
Enter Accommodation in box 32 and Color Vision (Test used and result) in box 33.
Enter Depth Perception (Test used and score) in box 34 as Uncorrected and Corrected.
Enter Field of Vision in box 35, Night Vision (Test used and result) in box 36, the Red Lens Test in box 37 and Intraocular Tension in box 38.
Boxes 39 to 41, hearing and psychological tests
Enter Hearing in box 39 and the Audiometer in box 40 for Right and Left.
Enter the Tests used and score for Psychological and Psychomotor in box 41.
Boxes 42 to 44, notes, summary and recommendations
In box 42 Notes (Continued) and Significant or Interval History, use additional sheets if necessary.
In box 43 Summary of Defects and Diagnoses, list diagnoses with item numbers.
Specify Further Specialist Examinations Indicated in box 44 Recommendations.
Boxes 45 to 47, physical profile and qualification
Enter the Physical Profile in box 45A and the Physical Category in box 45B.
For box 46 Examinee (Check), mark Is Qualified For or Is Not Qualified For.
If not qualified, list disqualifying defects by item number in box 47.
Boxes 48 to 51, names and signatures
Enter the Typed or Printed Name of Physician and a Signature in box 48.
Enter the Typed or Printed Name of Physician and a Signature in box 49.
Enter the Typed or Printed Name of Dentist or Physician (Indicate which) and a Signature in box 50.
Enter the Typed or Printed Name of Reviewing Officer or Approving Authority and a Signature in box 51.
More rules for Standard Form 88
Enter the Name, the Identification and the No. of Sheets Attached.
Sources
[1] Standard Form 88 (Rev. 10-94), Medical Record Report of Medical Examination, U.S. General Services Administration (the Official source link on this page).