Health History & Physical Examination Form - Suny Poly Page 3
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4PHYSICAL EXAMINATION
Health Care Provider Completes
Student Name ______________________________________________________ Birth Date ___ ___-___ ___-___ ___ ___ ___
Female
Male
Age
Height
Weight
Blood Pressure:
Pulse:
Allergies:
Vision: Right 20/
Corrected: Right 20/
Color Vision:
Hearing: Right
Left
20/
Left 20/
Left
CLINICAL EVALUATION -
Check each item in proper column. Enter NE if Not Evaluated
Physical Exam Date
Normal
Abnormal
Notes/Details
____________________
1. Skin (scars, tattoos)
2. Ears
3. Head/eyes
4. Nose
5. Mouth/teeth
6. Throat/Neck
7. Lymphatic
8. Chest/breast
9. Heart
10. Lungs
11. Abdomen (including hernia)
12. Endocrine
13. Allergic/Immunologic
14. Genito/urinary
15. Rectal/pelvic
16. Extremities (strength, ROM, etc.)
17. Spine/other musculo-skeletal
18. Neurologic
19. Psychiatric
Additional Comments:
Any issues/concerns that SUNY Poly should be aware of while providing episodic medical care to this college student:
Clearance as a Nursing Student/Health Care Provider
___________Yes __________No
Clearance as an Intercollegiate Athlete/ Sports Physical Exam
___________Yes __________No
Comments: ____________________________________________________________________________________________
_______________________________________________________________________________________________________
Examining Health Care Provider Name (Please Print)___________________________________________________________
Signature Examining Health Care Provider __________________________________________ Date: _________________
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