Order Of The Arrow - Boy Scouts Of America Health And Medical Record Form Page 4
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5Medical Evaluation
Physical Examination:
Vital Signs:
Blood Pressure: ________________ Pulse: ________________ Respiratory Rate: ________________ Temperature: ________________
Weight: ________________ Height: ________________
Normal
Abnormal
System
Explanation of Abnormalities
( if N/A)
HEENT
Neck
Lungs
Cardiovascular
Abdominal
Genitourinary
Skin
Back
Upper Extremities
Lower Extremities
Neurological
Special Information:
Yes
No
Explanation of Abnormalities
( if N/A)
Contact Lens
Glasses
Dentures
Prosthetic Limbs
Use a wheelchair
Last Stress Test/Results
Last Card Cath/Results
Restrictions or Limitations: (If no limitations exist then state so.)
Physician’s Approval:
A complete physical examination and review of the medical history must be completed by a licensed Physician to practice medicine. This
physical examination may be completed by a nurse practitioner or a certified physician’s assistant, but must be reviewed by the supervising
physician.
Physician Signature:
Physician Extender’s Signature:
Physician Name:
Physician Extender’s Name:
Address:
City, State, Zip:
Office Phone Number: (
)
Date:
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