Physical Examination Form
Physical Examination Form
Please provide all the necessary information below to complete this form.
Patient Information
Name
Date of Birth
Gender
-
Male
-
Female
Date of Exam
Medical History
Known Allergies
Current Medications
Past Medical Conditions
Family Medical History
Vital Signs
Height
Weight
Blood Pressure
Heart Rate
Respiratory Rate
Temperature
Alertness and Orientation
Skin Condition
Systemic Examination
Head, Eyes, Ears, Nose, Throat (HEENT)
Observations:
Cardiovascular System
Heart sounds, murmurs, etc.:
Respiratory System
Lung sounds, abnormalities:
Abdominal Examination
Tenderness, masses, etc.
Musculoskeletal System
Joint pain, range of motion
Neurological Examination
Assessment & Plan
Assessment Summary
Recommended Tests
Treatment Plan
Follow-Up Date
Physician's Information
Physician's Name
License Number
Date:
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