Physical Examination Form

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8/9 EXAMPLES

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LAST NAME
FIRST NAME
MIDDLE INITIAL
ID NUMBER
PHYSICAL EXAMINATION
INITIAL IMPRESSION
SIGNATURE OF PHYSICIAN
NAME OF PHYSICIAN
STANDARD FORM 506 BACK
MEDICAL RECORD
DATE OF EXAM
HEIGHT
WEIGHT
TEMPERATURE
PULSE
BLOOD PRESSURE
AVERAGE
MAXIMUM
PRESENT
INSTRUCTIONS - Describe (1) General Appearance and Mental Status; (2) Head and Neck (general); (3) Eyes; (4) Ears; (5) Nose; (6) Mouth; (7) Throat; (8) Teeth; (9) Chest (general); (10) Breast; (11) Lungs; (12) Cardiovascular; (13) Abdomen; (14) Hemmia; (15) Genitalia; (16) Pelvic; (17) Rectal; (18) Prostate; (19) Back; (20) Extremities; (21) Neurological; (22) Skin; (23) Lymphatics.
(Continue on reverse side)
RELATIONSHIP TO SPONSOR
SPONSOR'S NAME
SPONSOR'S ID NUMBER
(SSN or Other)
LAST
FIRST
MI
DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY
RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION:
(For typed or written entries, give: Name - last, first, middle; ID No. or SSN; Sex; Date of Birth; Rank/Grade)
REGISTER NO.
WARD NO.
PHYSICAL EXAMINATION Medical Record
STANDARD FORM 506