Form Approved
OMB No.0920-XXXX
Exp. Date xx/xx/20xx
Physical Health |
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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) |
|
|
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Head/Fontanelle |
Normal
Normal |
Abnormal (please specify): __________________(free type)
Abnormal (please specify): __________________(free type) |
Ears |
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Structure |
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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 Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Kotzky, Kim (CDC/ONDIEH/NCBDDD) (CTR) |
File Modified | 0000-00-00 |
File Created | 2021-01-22 |