AARS #8306
RT - 3, RT - 24, RT-52, GP-27
REV. 6/13
MEDICAL EXAMINATION FORM
SECTION I
File# ________
Name ___________________________________
Last
First
Middle
_____/_____/_____
Birth date
______
Sex
Address_____________________________________________________________________________
Last time hospitalized - date _____/_____/_____ reason ______________________________________
name and location of hospital ____________________________________________________________
Presently under care of physician?
if yes, give name and address ________________________
____________________________________________________________________________________
Chronic illness/Conditions _______________________________________________________________
SECTION II
PHYSICAL EXAMINATION - TO BE FILLED OUT BY A PHYSICIAN. Use check (x) for
items found normal, note deviations from normal. If items need further information, record on extra sheet.
It is important that complete medical information be recorded, fill in form as fully as possible from exam
and previous records. Need to have information to determine extent of physical deterioration, to identify
possible handicapping conditions, and to determine appropriateness for long term alcoholism treatment.
Height _____ ft. _____ in.
Weight _____ lbs. Temperature _____ F.
Eyes: Right ____________________________ Left ____________________________
Distant vision: without glasses - R. 20/____ L.20/____
Ears:
with glasses - R.20/ ____ L.20/____
Right _______________________________ Left _________________________(at 20 ft.)
other findings: R. _________________________ L. ___________________________
Nose _________________________________ Throat ______________________________________
Lymphatic system _______________________ Breasts ______________________________________
Lungs ________________________________ Heart _______________________________________
Blood pressure ___________________ Pulse _________________ Dyspnoea ____________________
Cyanosis ______________________________ Edema_______________________________________
Abdomen____________________________________________________________________________
Hernia ______________________________________________________________________________
Genito-Urinary________________________________________________________________________
Gynecological ________________________________________________________________________
(prolapse, cystocele, rectocele, cervix)
Last Monthly Period ___________________________________________________________________
Ano-rectal (including prostate)
__________________________________________________________
Neurological__________________________________________________________________________
Psychiatric ___________________________________________________________________________
Skin ____________________
Feet ___________________
Varicosity _______________________
Orthopedic Impairments, describe ________________________________________________________
Name ___________________________________
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Lab Tests
(HTLV & HEPATITIS - OPTIONAL)
HTLV Date: ___/___/___
Results __________________________________________
HEPATITIS
Date: ___/___/___
serologic test for syphilis:
Results __________________________________________
Date _____/_____/_____
Name of test _______________________
Result ____________________________________________________
Urinalysis:
Date _____/_____/_____
Specific gravity ______________________________
Reaction _______________ Albumen _______________ Sugar ________________
Chest X-ray: Date _____/_____/_____ Results: ________ Hemoglobin: Date _____/_____/_____
TB-Skin Test: Date _____/_____/_____ Results: __________ Results: __________
Diphtheria/Tetanus Booster: Current immunization required date given: _____/_____/_____
RECOMMENDATIONS
Is examination by a specialist advisable? if so, please specify specialty
__________________________________________________________________________________
refraction
X-ray of chest
Hemoglobin
Other diagnostic procedures or services (specify) ___________________________________________
Hospitalization (reasons and estimate duration) _____________________________________________
___________________________________________________________________________________
Treatment (type and estimate duration) ____________________________________________________
___________________________________________________________________________________
Re-examination or Re-evaluation, how soon _______________________________________________
SECTION III
PHYSICIAN'S CONCLUSIONS AND COMMENTS
PLEASE CHECK ALL ACTIVITIES CLIENT CAN DO
perform daily hygienic routines
dress unassisted
lifting
pulling
control body eliminations
feed self
climbing
walking
communicate with others
move about freely
pushing
standing
please include other activities client should avoid or cannot do __________________________________
Does client exhibit any of the following:
Psychosis or Psychoneurosis? explain (DSM IV) _____________________________________________
Current medications ____________________________________________________________________
History of Inhalant abuse, head injury? explain _______________________________________________
Potential danger to self or others? explain __________________________________________________
Suicidal?_____________________________________________________________________________
Communicable Disease? explain _________________________________________________________
Any special accommendations needed?____________________________________________________
Physician (print) _______________________________________
Date _____/_____/_____
Signature ____________________________________________
Address___________________________________________________________________
Name ___________________________________
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