Physical Health Exam

Zika Outcomes and Development of Infants and Children (ZODIAC) Investigation

Att. 8D - Physical Health Exam

Physical Health Exam

OMB: 0920-1194

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Form Approved

OMB No.0920-XXXX

Exp. Date xx/xx/20xx



Physical Health

Participant ID

_______________________

Name of Assessor

__________________(free type)

Name of Data Clerk

__________________(free type)

Date of assessment

______ (day – 2 digits) ______ (month – 2 digits) __________ (year – 4 digits)




Head/Fontanelle



Normal



Normal



Abnormal (please specify): __________________(free type)

Abnormal (please specify): __________________(free type)

Ears

Structure

Appears to

hear/responds to

sound

Yes

No (please specify): __________________(free type)

Eyes



Structure

Normal

Abnormal (please specify): __________________(free type)

Appears to

see/responds to

visual stimuli

Yes

No (please specify): __________________(free type)

Skin



Nevi

No

Yes (please specify): __________________(free type)

Café au lait

spots

No

Yes (please specify): __________________(free type)

Bruising

No

Yes (please specify): __________________(free type)



Nose



Normal



Abnormal (please specify): __________________(free type)

Mouth and Throat

Normal

Abnormal (please specify): __________________(free type)

Teeth



Caries

No

Yes (please specify): __________________(free type)

Eruption

Normal

Abnormal (please specify): __________________(free type)

Appearance

Normal

Abnormal (please specify): __________________(free type)

Lungs

Normal


Abnormal (please specify): __________________(free type)

Heart

Normal

Abnormal (please specify): __________________(free type)

Femoral pulses

Normal

Abnormal (please specify): __________________(free type)

Abdomen

Normal

Abnormal (please specify): __________________(free type)

Genitalia

Normal

Abnormal (please specify): __________________(free type)

Structure

Normal

Abnormal (please specify): __________________(free type)

Male testes

descended

(if applicable)



Yes



No (please specify): __________________(free type)

Extremities and Hips

Normal

Abnormal (please specify): __________________(free type)

Arthrogryposis

No

Yes (please specify): __________________(free type)

Back

Normal

Abnormal (please specify): __________________(free type)




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorKotzky, Kim (CDC/ONDIEH/NCBDDD) (CTR)
File Modified0000-00-00
File Created2021-01-22

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