Medical Report

Name (Last, First, MI): DATE:

Birth Date: / / Age: Civil Status:

Phone Numbers: Mobile: ) Sex:

Height: Weight: BLD Pressure: Pulse:

Respiration: BMI:

Medical History
COMPANY NAME: Contact Number:

Physician : DR. Address:

Do you have any of the following?: Yes No Do you have any of the following?: Yes No
Weight loss / Weight gain (circle) Palpitations or skipped beats
Fevers Chest pain or tightness
Headaches Indigestion/heartburn
Difficulty with vision / Wear lenses or glasses Abdominal pain
Dizziness / Vertigo Diarrhea/constipation
Difficulty hearing Irregular periods
Seasonal allergies Frequent urinary tract infections
Sinus problems Kidney stones
Tiredness or falling asleep during the day Back pain
Unable to tolerate heat or cold Joint pain or swelling
Shortness of breath with or without exertion A history of broken bones
Wheezing Swelling of the legs
Cough Skin problems (rash, eczema, psoriasis)

If yes, when? treated?

If yes, what? treated?

Physical Examination Yes No Findings

1. Skin
2. Head, Scalp
3. Eyes
4. Ears
5. Nose, Sinuses
6. Mouth, Throat
7. Thyroid, Neck
8. Breast - Axilla
9. Lungs
10. Heart
11. Abdomen
12. Back
13. Anus-rectum
14. G-U System
15. Inguinals, Genitals
16. Extremities
Physician’s Signature: