___ Nervous Stomach             ___ Cardiovascular Disease                  ___ Seizures (Convulsions)

___ Kidney Disease                 ___ Sexually Transmitted Disease       ___ Any Other Diseases

 
Explain any of the checked diseases listed above: ____________________________________________________________________________________

____________________________________________________________________________________

General appearance and development:          Good__________  Fair__________  Poor__________

Vision:                                                                                 Without corrective lens            ___Yes  ___No

For distance: Right 20/______  Left 20/______        With corrective lens, if worn    ___ Yes ___No

Evidence of disease or injury:   Right eye_________________  Left eye___________________

Hearing:           Right ear________________________________  Left ear___________________

Disease or injury________________________________________________________

Throat: _____________________________________________________________________________

Thorax:  Heart____________________If organic disease is present, is it fully compensated?______

Blood Pressure:         Systolic____________   Diastolic________________

Lungs:__________________________________________________________

Abdomen:  Scars_______________  Abnormal Masses_______________ Tenderness___________

Extremities:  Upper______________  Lower_____________________ Reflexes__________________

Laboratory and other special findings:

            Urine: Spec. Gr._______________  Alb._______________ Sugar______________

            HIV:      ___Negative  ___Positive

____________________________________________________________________________________

General Comments:

 

 

 

 

 

 

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Information on Examining Physician:

Name:_____________________________________  Signature:_______________________________

Address:____________________________________________________________________________



Medical License #__________________________________  


Date of Examination________________