Physical Examination Reporting Form

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April Stanley
5 years ago
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1 Building Trades National Medical Screening Program Physical Examination Reporting Form Name: Date: P1. Vital Signs Height: BP: / Weight: lbs. #2 nd BP:* / Arm: L R Cuff Size:** Regular Large Ped Pulse: Rate: (check one) Regular Irregular *2 nd blood pressure should be taken later in the visit if first reading SBP is > 140 and/or DBP > 90. **Reference table for cuff size: P2. General Arm Circumference (cm) Cuff Size Pediatric Adult Large Adult Thigh The participant is well-developed, well-nourished, and appears well. Other: (describe): P3. Skin Normal skin without rashes or lesions of concern. Additional Findings: Multiple moles Fair complexion Single mole Seborrheic keratosis Tanned skin Scar due to injury Other (describe): P4. Mouth and Throat Adequate dental hygiene, oral cavity normal without lesions Other: (describe): Page 1 of 5

2 P5. Eyes/Vision When was patient s last eye exam? (Number of years ago) Visual acuity (check one): Corrected Not corrected If corrected: Glasses Contact lenses (Snellen Chart) Normal 20/20 Right eye Left eye P6. Ears Normal extraocular movements and pupils Normal fundoscopic examination Other (describe): Normal external canals and tympanic membranes P7. Neck/Thyroid Normal exam Abnormal additional findings (Check all that apply & describe if needed) Thyroid enlarged Palpable nodule(s) Carotid pulses abnormal (describe) P8. Lymph Nodes P9. Chest No adenopathy Normal, comfortable respirations (no respiratory distress) Clear to auscultation and percussion Decreased breath sounds Increased AP diameter Wheezes Pectus excavatum Crackles Scoliosis Hyperresonant Kyphosis Page 2 of 5

3 P10a. Breasts (Females) Breasts symmetrical without masses or discharge Additional Findings (check any and all that apply and describe if needed): Mass Cystic breasts Deferred breast exam P10b. Breasts (Males) No gynecomastia or breast nodules P11. Cardiovascular Normal cardiac exam Distant heart sounds Mid-systolic click I/VI (physiologic) SEM II/VI SEM III/VI SEM P12. Peripheral Pulses (If 45 Years of Age or Older) Pulses (check if present and normal): 0=absent, 1=decreased, 2=normal Right Left Brachial Radial Femoral Dorsalis pedis Posterior tibial Other: Page 3 of 5

4 P13. Abdomen Bowel sounds are normal The liver and spleen are not enlarged There are no masses or bruits There is no pain or tenderness on palpation Obese RLQ tenderness Surgical scar LLQ tenderness Diffuse tenderness P14. Pelvis and Groin (Males) No hernias Testicles descended without nodules (Age 45 and above) Normal prostate (Age 45 and above) No rectal masses Enlarged prostate Participant deferred pelvis/groin examination Immunochemical Fecal Occult Blood Test (FIT) (circle): Negative Positive Not Performed or (FOBT) Guaiac testing: Number of stool cards tested (circle): Number Positive (circle): Page 4 of 5

5 P15. Musculosketal/Extremities No edema Full range of motion of large joints without effusion Additional Findings (check any that apply and describe, including the location): Joint effusions: Muscle tenderness: Joint pain: Muscle atrophy: Joint swelling: P16. Neurological Normal gait and coordination Normal cranial nerve function Normal proximal and distal strength Normal touch sensation Normal mental status Other (describe) Reflexes: Right Left Biceps Triceps Knee Ankle Reflex Scale Clonus 4+ Slightly hyperreflexive 3+ Normal 2+ Decreased 1+ Absent 0 Physician s Signature / / Page 5 of 5

MARYWOOD UNIVERSITY PHYSICIAN ASSISTANT PROGRAM HISTORY, PHYSICAL, ASSESSMENT AND PLAN

MARYWOOD UNIVERSITY PHYSICIAN ASSISTANT PROGRAM HISTORY, PHYSICAL, ASSESSMENT AND PLAN PA: PRECEPTOR: MARYWOOD STAFF: PATIENT ID: AGE: SEX: DATE: Chief Complaint: History of Present Illness: 1 Medications: