Physical Exam Form

Attachment 15 Physical Exam Form.doc

Registry of Unexplained Fatiguing Illnesses and Chronic Fatigue Syndrome (CFS): A Pilot Study

Physical Exam Form

OMB: 0920-0788

Document [doc]
Download: doc | pdf

2

05/17/07






A ttachment 15







Physical Exam Form





Physical Exam Form



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:__ __ __

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:__ __ __

System

Not

Done

Normal

Abnormal

If abnormal, explain or describe below:

1

Oral




2

Head and Neck





3

EENT





4

Thyroid





5

Chest




6

Heart





7

Lungs






Section 5: Physical Examination (cont’d, part 2) STAFF ID:__ __ __

8

Abdomen





9

Liver



10

Spleen


11

Extremities




12

Skin




13

Neurological




14

Pulses


15

Lymph nodes



16

Joints and muscles





17

Mental status





Section 5: Physical Examination (cont’d, part 3) STAFF ID:__ __ __

18

Other (specify):

_____________






19

Other (specify):

_____________






20

Other (specify):

_____________








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


_____________________________________




File Typeapplication/msword
File Title
AuthorWESLEY
Last Modified Byevm3
File Modified2007-11-21
File Created2007-05-31

© 2024 OMB.report | Privacy Policy