Physical Health Examination Form printable pdf download

Physical Health Examination Form

WINGS -JAYC II, LLC

Office - 320-593-0440; Fax 320-593-0442

Physical Health Examination

Client: _________________________________ Date of physical Exam: ______________________

Diagnosis code(s) _________________; ______________________; ___________________________

Name of Physician Completing Physical Exam: ___________________________________________

Doctor’s office Phone: ____________________________________

Pertinent Findings: Must include a review of systems and statement that the resident is free of

communicable disease as well as other information requested here:

Past Illness -check all that apply

_____ Allergies

______ Kidney Disease

_____ Heart Attack

_____ Digestive Disease

_____CVA

_____ Cancer

_____ Thromobophlebitis

_____ Bladder Infection

_____ Thyroid Disease

_____Childbirth Complications

_____Liver Disease

_____Arthritis

_____Serious Injury

_____ Fractures

_____ Surgery

_____ Use of Alcohol

_____ Use of cigarettes

_____ Use of drugs

_____ Skin

_____ Venereal Disease

_____ Use of prescription drugs

_____ Other (please explain below)

Explanation:

_____________________________________________________________________________________

Date of Last Tetanus: ___________________________________________________________________

Physical Examination:

Blood Pressure: __________ Temperature __________ Pulse : ____________Respirations___________

Weight: __________ Height:__________ Urinalysis for Drug Screen: _____________________

Physical Health Examination Form