DOD Medical Form: History and Physical Exam Form - Blank

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DOD Medical Form: History and Physical Exam Form - Blank

Doc_type: 
Other
Rec_aclu_path: 
https://www.thetorturedatabase.org/node/4304
Doc_pdf_path: 
Doc_rel_date: 
Tuesday, February 14, 2006
Doc_text: 

History and Physical Exam Form

Name: Date:
ISN: VS: BP: Pulse:

DOB: AGE: Resp: Temp:

Gender: Male / Female Height: Weight:

Complaint: Acute: PMH: DM HTN STD TB Chronic: Hosp: Surg: Medications: Allergies:

SocHx: Tobacco YIN
PPDx yrs
EtOH
ROS: HEENT: CXR: Normal / Abnormal
CV: Findings:
PULM:

GI: PPD: Date placed: / /

GU: Date read: / /
OB/GYN: mm
MS:

NEURO: Immunizations: (given at this time)
DERM:
ENDO: MMR Td Typhoid Polio
PSYCH:

Influenza Meningococcal Physical Exam: HEENT: Normal / Abnormal
CV: Normal / Abnormal PULM: Normal / Abnormal GI: Normal / Abnormal GU: Normal / Abnormal OB/GYN: Normal / Abnormal / NA MS: Normal / Abnormal PhotographNEURO: Normal / Abnormal DERM: Normal / Abnormal ENDO: Normal / Abnormal PSYCH: Normal / Abnormal
Comments / Findings:
Impression:
Plan:
Provider Signature: Printed Name / Stamp:

Doc_nid: 
4304
Doc_type_num: 
75