Physical Examination And Medical History Form Page 2
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4Vinland National Center
PO Box 308
Loretto, Mn 55357
Phone: 763-479-3555
Fax: 763-479-4372
E-Mail:
VINLAND CHEMICAL DEPENDENCY PROGRAM HISTORY & PHYSICAL
Page 2 of 2
Temp
BP
Pulse
Resp.
SaO
Height
Weight
2
Physical Exam: (Check appropriate box, provide explanation for abnormal finding below):
NL
ABN
NL
ABN
Head
Head atraumatic
Back
Inspection
Eyes
Pupils, EOM
Conjunctiva
ABD
Bowel sounds
Ears
TM’s, external ear canal
Tenderness
Masses/hernia
Nose
Nares
Organomegaly
Mouth
Throat
Pharynx
Extremities
Inspection
Joints
Neck
Tenderness
Strength
Range of Motion
Feet
Thyroid
Lymph nodes
Neurologic
Orientation
Mood
Respiratory
Breath sounds
Gait
Chest wall symmetry
Cranial nerves grossly intact
A/P diameter
Reflexes: Achilles/Patella
Gross motor
Cardiac
Rate and rhythm
Tremor
Heart sounds
Carotids if over 50
Skin
Inspection
Peripheral pulses
(Rashes, open wounds?)
Describe abnormal findings from physical examination:
Name of examining physician/practitioner (please print): _____________________________________________________________
Clinic name: __________________________________________________________________________________________________
Clinic address: ________________________________________________________________________________________________
Physician/Practitioner phone: __________________________________
fax: _________________________________
Physician/Practitioner signature/title: _________________________________________________ Date: (mm/dd/yyyy)__/__/____
Pre-admission H & P
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