AARS #8306 RT - 3, RT - 24, RT-52, GP-27 REV. 6/13

MEDICAL EXAMINATION FORM SECTION I File# ______Name ______/_____/______Last First Middle Birth date Sex Address______

Last time hospitalized - date _____/_____/_____ reason ______name and location of hospital ______Presently under care of physician? if yes, give name and address ______Chronic illness/Conditions ______SECTION II PHYSICAL EXAMINATION - TO BE FILLED OUT BY A PHYSICIAN. Use check (x) for items found normal, note deviations from normal. If items need further information, record on extra sheet. It is important that complete medical information be recorded, fill in form as fully as possible from exam and previous records. Need to have information to determine extent of physical deterioration, to identify possible handicapping conditions, and to determine appropriateness for long term alcoholism treatment.

Height _____ ft. _____ in. Weight _____ lbs. Temperature _____ F. Eyes: Right ______Left ______Distant vision: without glasses - R. 20/____ L.20/____ with glasses - R.20/ ____ L.20/____ Ears: Right ______Left ______(at 20 ft.) other findings: R. ______L. ______Nose ______Throat ______Lymphatic system ______Breasts ______Lungs ______Heart ______Blood pressure ______Pulse ______Dyspnoea ______Cyanosis ______Edema______Abdomen______Hernia ______Genito-Urinary______Gynecological ______(prolapse, cystocele, rectocele, cervix) Last Monthly Period ______Ano-rectal (including prostate) ______Neurological______Psychiatric ______Skin ______Feet ______Varicosity ______Orthopedic Impairments, describe ______

Name ______# ______

1 of 2 #8306 Lab Tests

(HTLV & HEPATITIS - OPTIONAL) HTLV Date: ___/___/___ Results ______HEPATITIS Date: ___/___/___ Results ______

serologic test for syphilis: Date _____/_____/_____ Name of test ______Result ______Urinalysis: Date _____/_____/_____ Specific gravity ______Reaction ______Albumen ______Sugar ______Chest X-ray: Date _____/_____/_____ Results: ______Hemoglobin: Date _____/_____/_____ TB-Skin Test: Date _____/_____/_____ Results: ______Results: ______Diphtheria/Tetanus Booster: Current immunization required date given: _____/_____/_____

RECOMMENDATIONS Is examination by a specialist advisable? if so, please specify specialty ______refraction X-ray of chest Hemoglobin Other diagnostic procedures or services (specify) ______Hospitalization (reasons and estimate duration) ______Treatment (type and estimate duration) ______Re-examination or Re-evaluation, how soon ______SECTION III PHYSICIAN'S CONCLUSIONS AND COMMENTS PLEASE CHECK ALL ACTIVITIES CLIENT CAN DO perform daily hygienic routines dress unassisted lifting pulling control body eliminations feed self climbing walking communicate with others move about freely pushing standing

please include other activities client should avoid or cannot do ______Does client exhibit any of the following: Psychosis or Psychoneurosis? explain (DSM IV) ______Current medications ______History of Inhalant abuse, head injury? explain ______Potential danger to self or others? explain ______Suicidal? ______Communicable Disease? explain ______Any special accommendations needed?______Physician (print) ______Date _____/_____/_____ Signature ______Name ______# ______

2 of 2 #8306 Address______

Name ______# ______

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