ANNUAL PHYSICAL EXAMINATION

PERSONAL DATA
NAME: Last First: Middle: Birthdate:
Ht Wt BP CR RR
Vision: ( ) with Glass or Contact ( ) 20/20 vision
Are there any abnormalities in the following system?
Yes No
1. HEENT
2. Respiratory
3. Cardiovascular
4. Gastrointestinal
5. Genito – Urinary
6. Metabolic/Endocrine
7. Nervous System
8. Psychiatric
9. Skin
10. Musculoskeletal
Past Medical Examination:
1. Previous
Hospitalization:_________________________
2. Allergy:_______________________________

Vaccine: ____________________________________

PHYSICAL EXAMINATION:

General Appearance: Conscious, Coherent NICRD

HEENT: Anicteric Sclera, Pink Palpebral Conjunctiva, ( ) TPC Ear:_____________________
Chest/Lungs Symmetrical Chest Expansion, Clear Breath sound
Heart: Adynamic Precordium, Normal rate, normal rhythm
Abdomen: Normoactive bowel sound
Skin/Extremities: Normal skin; Full equal Pules
Dental: ___________________________________________

I have examined the above student and certify that he/she is physically fit

Date: __________________________________

__________________________________________