Adult Health Examination Record Page 2
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2ADULT HEALTH EXAMINATION RECORD
- to be completed by Physician
Name:____________________________________________________Date:______________________
Instructions: Please ask applicant to show you a written description of the event/assignment so that you may determine
whether she/he is in condition to participate in this particular event/assignment and to insure that the applicant has the
valid immunization required.
Examination Findings— check box if condition is satisfactory. If not, explain in space provided below.
Eyes and vision
Ears and Hearing
Menstrual Pain
Abdomen
Chest X-ray (if required)
Legs (for camping and
Skin
Heart
primitive conditions)
Other
Throat
Lungs
Exact Measurement of:
Blood Pressure
Pulse Rate
Urinalysis: SP Gravity
Sugar
Albumin
Blood Hemoglobin
Height
Weight
Does applicant have any condition which might limit activity for this event/assignment?
Yes
No
Does applicant have any chronic diseases?
Yes
No
If overweight, will condition restrict activity?
Yes
No
Does applicant have any condition which might limit her/his participation in swimming, hill climbing and other strenuous
activities?
Yes
No
If any of the above were unsatisfactory, or if applicant has any limitations, use this space to explain.
Immunizations — Fill in date of valid immunizations applicant has had.
Only those requested on the
announcement of the event are required.
Immunization
Date Last Received
Immunization
Date Last Received
Hepatitis B
Typhoid and Paratyphoid
Tetanus (within 10 years)
Cholera
Typus
Yellow Fever
Polio—complete series or booster required
Gama Globulin (Hepatitis)
Rocky Mt. Spotted Fever (entire series)
Other—
German Measles (Rubella)
Statement of Physician:
Applicant is in good physical condition and able to participate in this event/assignment.
Yes
No
Applicant should not participate in this event for the following reasons:
Name of Physician
Signature
Address
Date
Health Exam - Adult_v1
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