J-12 Physical Exam Form.pdf

117 KB Posted

Attached to
World Trade Center National Responder Health Program Contract
Solicitation number
2010-N-12135
Issued by

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J-12

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A. General Information

Physician Name (Last, First) Exam Location

Patient Name (Last, First) Today’s Date (MM/DD/YY)

Patient DOB (MM/DD/YY)

World Trade Center Responder Health Program Physical Health Examination

B. Vital Signs

BP _______ / _______ Pulse _______ Pulse irregular (describe)

Respirations _______ Height _______ Weight _______ BMI _______

C. General Appearance

Normal Abnormal Ill-appearing Obese Wasted

Description

Coughing during examinations

If coughing during examination: Minimal Moderate Heavy

D. Ears

Normal Abnormal

If abnormal, describe

E. Eyes

Normal Abnormal

If abnormal, describe

F. Nose

Normal Abnormal

If abnormal, describe

G. Sinuses

Normal Abnormal

If abnormal, describe

H. Mouth/Throat

Normal Abnormal

If abnormal, describe

I. Neck

Normal Abnormal

If abnormal, describe

J. Chest

Normal Abnormal

If abnormal, describe

Shape/Deformities Barrel Chest Kyphosis Scoliosis Breathing Pattern Asymmetrical

Description

Auscultation

Findings Describe

Rales

Wheezing

Rhonchi

Diminished Breath Sounds

K. Heart

Normal Abnormal

If abnormal, describe

L. Abdomen

Normal Abnormal

If abnormal, describe

M. Extremities

Normal Abnormal

If abnormal, describe

N. Skin

Normal Abnormal

If abnormal, describe

O. Musculoskeletal

Normal Abnormal

If abnormal, describe

P. Neurological

Normal Abnormal

If abnormal, describe

Physician Signature Today’s Date

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