Medical Physical Form - 24 Items Page 2

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REPORT OF MEDICAL EXAMINATION
NORMAL ABNORMAL CHECK EACH ITEM IN APPROPRIATE BOX
NOTES: Describe every abnormality in
1. Head, face, neck and scalp
detail, enter applicable item number
2. Nose
before each comment. Use additional
3. Sinuses
sheets if necessary and attach to this
4. Mouth and throat
form.
5. Ears, general (internal and external canals)
6. Ear Drums (perforation)
7. Eyes, general (visual activity under items 50 &51)
8. Ophthalmoscopic
9. Pupils (equality and reaction)
10. Ocular mobility (associated parallel movement, mystaginus)
11. Lungs and chest (including breasts)
12. Heart ( thrust, size, rhythm, sounds)
13. Vascular system
14. Abdomen and viscera (including hernia)
15. Anus and rectum (hemorrhoids, fistula, prostate)
16. Endocrine system
17. G-U system
18. Upper and lower extremities ( strength, range of motion)
19. Spine other musculoskeletal
20. Identifying body marks, scar, tattoos
21. Skin and lymphatic
22. Neuralgic (tendon reflexes, equilibrium, senses, coordination)
23. Psychiatric (specify any personality deviation)
24. General Systemic
Corrective lens required while driving
FIELD OF VISION
DISTANT VISION
NEAR VISION
20/
20/
[ ] NO * if previously
Right eye
[ ] YES
[ ] Normal
“yes”, please include
explanation of change
20/
20/
Left eye
[ ] Abnormal
20/
20/
Both eyes
BLOOD SUGAR TEST
FIELD OF VISION
(both fasting and 2 hour post prandial, required only if sugar is found in urine No S.I. Units))
RIGHT EYE
LEFT EYE
FASTING
2-HOUR P.P.
HgA 1C
COMMENTS
PULSE (Wrist)
BLOOD PRESSURE
Recumbent MM
Systolic
Diastolic
Resting
After Exercise
2 minutes after exercise
Mercury
ECG (Date)
URINALYSIS
OTHER TESTS
Albumen
Sugar
Req 55 or over
DISQUALIFYING DEFECTS/LIMITATIONS:
COMMENTS ON HISTORY AND FINDINGS:
APPLICANTS NAME:
FURTHER EVALUATION REQUIRED (EXPLAIN):
PHYSICALLY ACCEPTABLE
MEDICAL EXAMINER’S DECLARATION: I hereby cerify that I personally examined the applicant named on this medical examination repot, and that this report and
any attachment embodies my findings completely and correctly.
MEDICAL EXAMINER’S NAME AND ADDRESS
MEDICAL EXAMINER’S SIGNATURE
EXAMINATION DATE

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