Va Form 0927c - Participant Registration Form - Physical Exam Page 2
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1
2PATIENT'S NAME
SOCIAL SECURITY NUMBER
(Last 4 digits only)
MEDICAL HISTORY (i.e., diabetes, heart disease, hypertension, respiratory difficulty)
LIST ALL MEDICATIONS, INCLUDING ASPIRIN AND OTHER "OVER THE COUNTER" MEDICINE/SUPPLEMENTS
KNOWN ALLERGIES
DATE OF LAST TETANUS SHOT
IS THE PATIENT TAKING COUMADIN
IF YES, WHICH
YES
NO
OR OTHER ANTICOAGULANTS?
DOES THE PATIENT SMOKE?
YES
NO
ALCOHOL OR OTHER SUBSTANCE USE?
YES
NO
PHYSICAL EXAM
HEIGHT
WEIGHT
PULSE
(inches)
(pounds)
CARDIAC
BLOOD PRESSURE
HEAD & NECK
PULMONARY
ABDOMEN
EXTREMITIES
HEENT
NEURO
OTHER FINDINGS
IN MY OPINION, THE ABOVE INDIVIDUAL:
IS MEDICALLY FIT TO PARTICIPATE
IS NOT MEDICALLY FIT TO PARTICIPATE
SIGNATURE OF EXAMING CLINICIAN
NAME OF EXAMING CLINICIAN (Please print)
ADDRESS OF EXAMINING CLINICIAN
TELEPHONE NUMBER
VA FORM 0927c, FEB 2013, page 2
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