Pre-Placement Physical Examination Form - KoreMe

Pre-Placement Physical Examination Form

Patient Name*

Date of Birth*

Sex*

Height*

Weight*

Body Fat % (optional):

Pulse*

Blood Pressure*

Waist/Hip Ratio*

PHYSICAL EXAM

Head

Normal*

Abnormal Findings*

Initials*

Eyes

Normal*

Abnormal Findings*

Initials*

Ears

Normal*

Abnormal Findings*

Initials*

Nose

Normal*

Abnormal Findings*

Initials*

Throat

Normal*

Abnormal Findings*

Initials*

Extremities

Normal*

Abnormal Findings*

Initials*

Thyroid

Normal*

Abnormal Findings*

Initials*

Skin

Normal*

Abnormal Findings*

Initials*

Abdomen

Normal*

Abnormal Findings*

Initials*

Lungs

Normal*

Abnormal Findings*

Initials*

Heart

Normal*

Abnormal Findings*

Initials*

Breasts Male/Female

Normal*

Abnormal Findings*

Initials*

Prostate (conditional)

Normal*

Abnormal Findings*

Initials*

General Appearance

Normal*

Abnormal Findings*

Initials*

Reflexes

Normal*

Abnormal Findings*

Initials*

Additional Findings*

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