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Pre-Placement Physical Examination Form
Patient Name
*
Date of Birth
*
Sex
*
Male
Female
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
*
Submit
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