<p> HEALTH SCIENCES Physical Examination Form</p><p>G Last Name First Name GWid</p><p>Email Phone Date of birth (MM/DD/YYYY) Term/Year First Admitted</p><p>Health Sciences Program (circle one): Clinical Lab Science Physician Assistant Physical Therapy</p><p>Physical Exam (Required annually for Health Sciences students engaging in clinical practice)</p><p>Age: _____ Height: ______Weight: ______Pulse: ______Blood Pressure: _____/_____ Temp:______Vision: Uncorrected: R____/____ L____/____ Both____/____ Corrected: R____/____ L____/____ Both____/____ </p><p>Normal Region Abnormal Findings Eyes</p><p>Ears, Nose, Throat</p><p>Mouth, Teeth</p><p>Neck</p><p>Cardiovascular</p><p>Chest, Lungs</p><p>Abdomen</p><p>Skin</p><p>Genitalia</p><p>Musculoskeletal</p><p>Neuromuscular</p><p>Remarkable Medical / Surgical History ______</p><p>______</p><p>Remarkable Family / Social History ______</p><p>______</p><p>Allergies ______</p><p>Medications ______</p><p>GW HEALTH SCIENCES Physical Examination Form (cont’d)</p><p>Revised June 2013</p><p>Last Name First Name GWid</p><p>Turberculin Skin Test (Mantoux) – Required Annually </p><p>Date Placed ____/____/____ Date Read ____/____/____ Result (in mm): ______</p><p>(If positive ONLY) Result of Chest X-Ray: ______Date of Chest X-Ray : ____/____/____</p><p>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.</p><p>______</p><p>Health Care Provider Signature or Stamp Date Health Care Provider Phone Number</p><p>Health Sciences Students -- Make a copy of the completed form for your own records. Submit BOTH pages of the form to: </p><p>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. </p><p>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. </p><p>Revised June 2013</p>