MEDICAL EXAMINATION FORM

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Last Name First Name Middle Initial Sex Age Civil Status
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Mailing Address: Date of Birth Place of Birth
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Next Kin (Relationship) Address Tel. No.
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Date of Examination Purpose of Examination
CLINICAL EVALUATION
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Physical Findings Describe Abnormality in detail

Normal : Abnormal Enter pertinent number for every comment

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2. Ears ________________________________
3. Nose ________________________________
4. Throat ________________________________
5. Teeth ________________________________
6. Lungs ________________________________
7. Heart ________________________________
8. Abdomen ________________________________
9. Genitalia ________________________________
10. Posture ________________________________
11. Extremeteis ________________________________
12. Skin ________________________________
13. Identfying Marks________________________________

MEASUREMENTS & OTHER FINDINGS:

Weight: ________________ Height: ____________ Color of Hair __________________ Color of Eyes

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Blood Pressure (Sitting) Systolic : __________________________ Diastolic :
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Vision : Distant Vision Right _________________________ Left
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Near Vision Right_________________________ Left
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Hearing: (ears) Right_________________________ Left

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Past Medical History Serious diseases, operations, injury, etc.
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LABORATORY FINDINGS

Blood Examination : Type ________________ etc.

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Urinalysis : Albumin _______________Sugar ______________
Microscopic____________________
Chest X-ray : Date Taken _______________________ Results
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Electrocardiogram: Date Taken _______________________ Results
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Other tests :
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REMARKS & RECOMMENDATION
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Signature of Examinee Medical Examiner/License No.