Download:
pdf |
pdfForm Approved
OMB No. 0920‐xxxx
Exp. Date xx/xx/xxxx
(affix label here)
Patient ID
Number
Site
Sub-site
Sequential ID
SEARCH Physical Examination Form
(to be completed for age 3 and older)
Anthropometric Measures
Examiner Code
1. Height:
.
.
cm.
cm.
Second
First
.
cm.
.
kg.
.
cm.
.
cm.
*Third
*Third measurement required if first two measurements differ by >0.5 cm.
2. Weight:
.
kg.
First
.
kg.
Second
*Third
*Third measurement required if first two measurements differ by >0.3 kg.
If PATIENT is wearing a non-removable
appliance, please specify the type of appliance.
3. Waist Circumference:
3a. NHANES waist circumference:
.
cm.
First
.
cm.
*Third
Second
*Third measurement required if first two measurements differ by >1.0 cm.
3b. Natural waist circumference:
.
cm.
.
cm.
*Third
*Third measurement required if first two measurements differ by >1.0 cm.
First
Second
Public reporting burden of this collection of information is estimated to average 180 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining data 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D‐
74, Atlanta, Georgia 30333; ATTN: PRA (0920‐xxxx).
SEARCH 3 Registry and Cohort Studies - Physical Exam form - 11-01-10
Page 1 of 2
Blood Pressure
Examiner Code
4. Extremity: (check one)
1
Right arm (preferred)
2
Left arm
5. Cuff size: (check one)
1
Infant
2
Child/Small Adult
3
Adult
4
6. Pulse Disappearance Pressure:
Lg. Arm
5
Thigh
mm. Hg
+30
7. Maximum inflation level (MIL):
mm. Hg
8. Blood Pressures:
Systolic
Diastolic
1st BP
mm. Hg.
2nd BP
mm. Hg.
3rd BP
mm. Hg.
8a. If unable to measure blood pressure, check reason:
1
Patient refused
1
Unable to determine MIL
1
Patient unable to sit
1
Unable to hear blood pressure sounds
1
Radial pulse not felt in either arm
1
Equipment malfunction
1
No cuff appropriate size
Acanthosis Nigricans
Examiner Code
9. Is Acanthosis Nigricans: (check one)
1
Yes
2
No
3
Maybe
FOR STUDY USE ONLY
Date Completed
Completed by
Month
Day
Year
Date Reviewed
Code
Reviewer Code
Month
Day
Year
Date Entered
Data Entry Code
Month
Day
SEARCH 3 Registry Study Physical Exam form - 11-01-10
Year
Page 2 of 2
File Type | application/pdf |
File Title | Microsoft Word - 4b15_physical exam cohort |
Author | stmoxley |
File Modified | 2011-09-09 |
File Created | 2011-09-09 |