HEADER: PI NAME, Protocol or IRB Number, Protocol Short Title

Subject Initials Subject ID Exam Date: / /

Month Day Year

Vital Sign Measurements (Standard)

Vital Sign Measurements not performed
Visit Number (check one):
Visit # Visit #
Visit # Visit #
Visit # Visit #

Height:
. inches Weight:
. lbs

Height not measured Weight not measured

Time: : (using 24 hour format of hh:mm)

Temperature:
. Fahrenheit Temperature not measured

Method: (check one) Oral Axillary Tympanic

Respiratory Rate: breaths/min Respiratory Rate not measured

Heart Rate: beats/min Heart Rate not measured

Systolic Blood Pressure mmHg Blood Pressure not measured

Diastolic Blood Pressure mmHg

Method: (check one) Manual Automated

Location: (check one) Left Arm Right Arm

Position: (check one) Sitting Supine Standing

Additional Notes:

Vital Sign Measurements obtained by:

Form Number Version Date: Page 1 of 1