Physical Health Examination Form Page 3
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4WINGS -JAYC II, LLC
Office - 320-593-0440; Fax 320-593-0442
Physical Health Examination
Review of System: Please explain all abnormal findings below:
Normal Finding
Abnormal
1. Skin
____________________________
_______________________________
2. Head
____________________________
_______________________________
3. Eyes
____________________________
_______________________________
Vision ____________________________
_______________________________
4. Ears
____________________________
_______________________________
Hearing ___________________________
_______________________________
5. Nasal Pharyngeal_____________________
_______________________________
6. Neck, Back, Extremities _______________
_______________________________
7. Breast ____________________________
_______________________________
8. Cardiovascular ______________________
_______________________________
9. Abdomen __________________________
_______________________________
10. Musculoskeletal _____________________
_______________________________
11. Repertory___________________________
_______________________________
12. Neurological ________________________
_______________________________
13. Glandular___________________________
_______________________________
14. Genital ____________________________
_______________________________
Pap Smear _________________________
_______________________________
Gonorrhea Culture___________________
_______________________________
15. Urinary Tract ________________________
_______________________________
16. Anorectal __________________________
_______________________________
Hemocult ___________________________
_______________________________
Does this resident require follow-up visits with a physician for physical health problems?
Yes
No
(circle one)
Type of Diet:
Regular
Special
(circle one)
Diagnosis and Impression of Health:
_____________________________________________________________________________________
_____________________________________________________________________________________
Additional Comments or recommendations:
_____________________________________________________________________________________
_____________________________________________________________________________________
Your Signature indicated you have informed the client of their conditions
Date:_________________
Phone: ____________________________
Address: _____________________________________________________
City _________________________State _____________________ZIP_______________
Physicians Signature: ________________________________________________________________
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Parent category: Education