A ttachment 15
Affix
Case ID Label Here
Please
indicate the month, day, and year in which the physical exam was
conducted. DATE:
/ /
Month Day Year
*ABTID:__ __ __ __ __ __ __ __ DATE: ____/____/____
Section 1: Vital Measurments STAFF ID:__ __ __ |
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Blood pressure (mmHg) |
Heart Rate |
Respiratory Rate |
/systolic diastolic |
beats/min |
breaths/min |
*Basal Temperature: .F*Weight: lbs. *Height: ft. in.*Neck Circumference: cm.*Waist Circumference: cm. *Hip Circumference: cm. |
1. On a scale of 1 to 10 how well do you feel today?
1…….2…….3…….4…….5…….6…….7…….8…….9…….10
Not well at all Very well
2. On a scale of 1 to 10, how tired do you feel today?
1…….2…….3…….4…….5…….6…….7…….8…….9…….10
Not tired at all Extremely tired
Section 5: Physical Examination STAFF ID:__ __ __ |
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System |
NotDone |
Normal |
Abnormal |
If abnormal, explain or describe below: |
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1 |
Oral |
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2 |
Head and Neck |
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3 |
EENT |
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4 |
Thyroid |
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5 |
Chest |
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6 |
Heart |
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7 |
Lungs |
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Section 5: Physical Examination (cont’d, part 2) STAFF ID:__ __ __ |
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8 |
Abdomen |
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9 |
Liver |
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10 |
Spleen |
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11 |
Extremities |
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12 |
Skin |
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13 |
Neurological |
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14 |
Pulses |
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15 |
Lymph nodes |
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16 |
Joints and muscles |
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17 |
Mental status |
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Section 5: Physical Examination (cont’d, part 3) STAFF ID:__ __ __ |
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18 |
Other (specify): _____________ |
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19 |
Other (specify): _____________ |
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20 |
Other (specify): _____________ |
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Impression: Please give a summary description of your overall impression of this patient
[mental status ,physical condition, over - or underweight, age corresponding to calendar or not, systems with problems, etc.
If you find anything abnormal -what differential diagnoses would you pursue should this be your (not a study) patient]
Section 6: Eligibility STAFF ID:__ __ __ |
*Eligible for Study: YES NO
*If not, Why?______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Signature
_____________________________________
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File Type | application/msword |
File Title | |
Author | WESLEY |
Last Modified By | evm3 |
File Modified | 2007-11-21 |
File Created | 2007-05-31 |