The George Washington University

HEALTH SCIENCES Physical Examination Form

G Last Name First Name GWid

Email Phone Date of birth (MM/DD/YYYY) Term/Year First Admitted

Health Sciences Program (circle one): Clinical Lab Science Physician Assistant Physical Therapy

Physical Exam (Required annually for Health Sciences students engaging in clinical practice)

Age: _____ Height: ______Weight: ______Pulse: ______Blood Pressure: _____/_____ Temp:______Vision: Uncorrected: R____/____ L____/____ Both____/____ Corrected: R____/____ L____/____ Both____/____

Normal Region Abnormal Findings Eyes

Ears, Nose, Throat

Mouth, Teeth

Cardiovascular

Chest, Lungs

Abdomen

Genitalia

Musculoskeletal

Neuromuscular

Remarkable Medical / Surgical History ______

______

Remarkable Family / Social History ______

______

Allergies ______

Medications ______

GW HEALTH SCIENCES Physical Examination Form (cont’d)

Revised June 2013

Last Name First Name GWid

Turberculin Skin Test (Mantoux) – Required Annually

Date Placed ____/____/____ Date Read ____/____/____ Result (in mm): ______

(If positive ONLY) Result of Chest X-Ray: ______Date of Chest X-Ray : ____/____/____

I certify this student:  Has received a physical examination;  Is found to be in good health and able to participate in classroom and clinical education components necessary to his/her program of study at the George Washington University.

______

Health Care Provider Signature or Stamp Date Health Care Provider Phone Number

Health Sciences Students -- Make a copy of the completed form for your own records. Submit BOTH pages of the form to:

GW Student Health Service ∙ ATTN: Health Sciences Student Compliance Program ∙ 2141 K Street, NW, Suite 501 ∙ Washington, DC 20052 ∙ Phone: 202-994-6827 ∙ Fax: 202-973-1572.

GW Student Health Services department will house all physical and immunization information. Upon receipt of this completed form, GW Student Health Services will initiate a tracking sheet to be stored in student’s file with program director or clinical coordinator of program of study.

Revised June 2013