SF88.pdf

EMAL E

MEDICAL RECORD REPORT OF MEDICAL EXAMINATION

DATE OF EXAM

1. LAST NAME - FIRST NAME - MIDDLE NAME 2. IDENTIFICATION NO. 3. GRADE AND COMPONENT OR POSITION

4. HOME ADDRESS (Number, street or RFD, city or town, state and ZIP code) 5. EMERGENCY CONTACT (Name and address of contact)

6. DATE OF BIRTH 7. AGE 8. SEX

FFEMALE MALE

9. RELATIONSHIP OF CONTACT

10. PLACE OF BIRTH 11. RACE

WHITE BLACK AMERICAN INDIAN/

ALASKA NATIVE

HISPANIC

WHITE

HISPANIC

BLACK

ASIAN/PACIFIC

ISLANDER

12a. AGENCY 12b. ORGANIZATION UNIT 13. TOTAL YEARS GOVERNMENT SERVICE

a. MILITARY b. CIVILIAN

14. NAME OF EXAMINING FACILITY OR EXAMINER, AND ADDRESS 15. RATING OR SPECIALTY OF EXAMINER

16. PURPOSE OF EXAMINATION

CLINICAL EVALUATION

(Check each item in appropriate column; enter "NE" if not evaluated.)NOR-

MAL

ABNOR-

MAL

A. HEAD, FACE, NECK AND SCALP

B. EARS-GENERAL (INTERNAL CANALS)

(Auditory acuity under items 39 and 40)

C. DRUMS

D. NOSE

E. SINUES

F. MOUTH AND THROAT

G. EYES-GENERAL (Visual acuity and refraction under items 28, 29, and 36)

H. OPTHALMOSCOPIC

I. PUPILS (Equality and reaction) J. OCULARMOTILITY (Associated parallel movements nystagmus)

K. LUNGS AND CHEST

L. HEART (Thrust, size, rythm, sounds) M. VASCULAR SYSTEM (Varicosities, etc.)

N. ABDOMEN AND VISCERA (Include hernia)

(Check each item in appropriate column; enter "NE" if not evaluated.)NOR-

MAL

ABNOR-

MAL

O. PROSTATE (Over 40 or clinically indicated)

P. TESTICULAR

Q. ANUS AND RECTUM (Hemorrhoids, Fistulae) (Hemocult Results)

R. ENDOCRINE SYSTEM

S. G-U SYSTEM

T. UPPER EXTREMITIES (Strength, range of motion)

U. FEET

V. LOWER EXTREMITIES (Except feet) (Strength, range of motion)

W. SPINE, OTHERMUSCULALSKELETAL

X. IDENTIFYING BODY MARKS, SCARS, TATTOOS

Y. SKIN, LYMPHATICS

Z. NEUROLOGIC (Equilibrium tests under item 41) AA. PSYCHIATRIC (Specify and personality deviation)

BB. BREASTS

CC. PELVIC (Females only)

NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 42 and use additional sheets if necessary.

18. DENTAL (Place appropriate symbols, shown in examples, above or below number of upper and lower teeth.)

1 2 3 32 31 30

Restorable Teeth

1 2 3 32 31 30

Non- Restorable Teeth x 1 2 3 32 31 30 x

Missing Teeth x x x 1 2 3 32 31 30 x x x

Replaced by dentures

( x ) 1 2 3 32 31 30 ( x )

Fixed Partial dentures

R I G H T

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

L E F T

REMARKS AND ADDITIONAL DENTAL

DEFECTS AND DISEASES

19. TEST RESULTS (Copies of results are preferred as attachments)

A. URINALYSIS: (1) SPECIFIC GRAVITY

(2) URINE ALBUMIN

(3) URINE SUGAR

4. MICROSCOPIC

B. CHEST X-RAY OR PPD (Place, date, film number and result)

C. SYPHILIS SEROLOGY (Specify test used and results)

D. EKG E. BLOOD TYPE AND

RH FACTOR

F. OTHER TESTS

NSN 7540-00-834-4038

88-120

STANDARD FORM 88 (Rev. 10-94) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-0.20

NAME IDENTIFICATION NO. NO. OF SHEETS ATTACHED

MEASUREMENTS AND OTHER FINDINGS

20. HEIGHT 21. WEIGHT 22. COLOR HAIR 23. COLOR EYES 24. BUILD

SLENDER MEDIUM HEAVY OBESE

26. TEMPERATURE

26. BLOOD PRESSURE ( Arm at heart level)

A.

SITTING

SYS.

DIAS.

B.

RECUM-

BENT

SYS.

DIAS.

C.

STANDING

(5 min.)

SYS.

DIAS.

27. PULSE (Arm at heart level) A. SITTING B. RECUMBENT C. STANDING (3 mins.) D. AFTER EXERCISE E. 2 MINS AFTER

28. DISTANT VISION

RIGHT 20/ CORR. TO 20/

LEFT 20/ CORR. TO 20/

29. REFRACTION

BY S. CX

BY S. CX

30. NEAR VISION

CORR. TO BY

CORR. TO BY

31. HETEROPHORIA (Specify distance)

FSO EXO R.H. L.H. PRISM DIV.

PRISM CONV.

CT PC PD

32. ACCOMMODATION

RIGHT LEFT

33. COLOR VISION (Test used and result) 34. DEPTH PERCEPTION (Test used and score) UNCORRECTED

CORRECTED

35. FIELD OF VISION

RIGHT LEFT

36. NIGHT VISION (Test used and score) 37. RED LENS TEST 38. INTRAOCULAR TENSION

RIGHT LEFT

39. HEARING

RIGHT WV /15 SV /15

LEFT WV /15 SV /15

40. AUDIOMETER

RIGHT

LEFT

41. PSYCHOLOGICAL AND PSYCHOMOTOR

(Tests used and score)

42. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY

(Use additional sheets if necessary)

44. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers)

44. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify) 45A. PHYSICAL PROFILE

P U L H E S

45B. PHYSICAL CATEGORY

A B C E

46. EXAMINEE (Check)

A. IS QUALIFIED FOR

B. IS NOT QUALIFIED FOR

47. IF NOT QUALIFIED, LIST DISQUALIFYING DEFFECTS BY ITEM NUMBER

48. TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE

49. TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE

50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which) SIGNATURE

51. TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY SIGNATURE

STANDARD FORM 88 (Rev. 10-94) PAGE 2