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This document is used by student-athletes to detail their medical history and undergo a physical examination to ensure they are fit to participate in sports activities. It outlines directions for

How to fill out physical examination record

How to fill out Physical Examination Record

1. Begin by entering the patient's personal information at the top of the form, including name, date of birth, and contact details.
2. Fill in the date of the examination and the name of the examining physician or healthcare provider.
3. Record the patient's medical history, including any current medications, allergies, and past illnesses or surgeries.
4. Note the patient's vital signs, such as blood pressure, heart rate, temperature, and respiratory rate.
5. Conduct a physical examination and document findings in the appropriate sections, covering various systems (e.g., cardiovascular, respiratory, gastrointestinal).
6. Include assessments of the patient's overall appearance, mobility, and any specific complaints they may have.
7. If necessary, record any pertinent diagnostic test results or referrals for further evaluation.
8. Review the completed record for accuracy and sign the form.

Who needs Physical Examination Record?

1. Individuals seeking employment that requires a physical examination.
2. Students entering schools or sports programs that mandate a health clearance.
3. Patients needing to establish care with a new healthcare provider.
4. Individuals applying for insurance coverage that requires a health evaluation.
5. Athletes participating in competitive sports.

People Also Ask about

How do you describe a physical exam?

Physical examination is the process of evaluating objective anatomic findings through the use of observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient's history and pathophysiology.

What are physical exam findings?

One of the first things a doctor will do during a physical examination is check your vital signs. These include your blood pressure, heart rate, respiratory rate, and temperature. Normal ranges for adults are as follows: Blood Pressure: 120/80 mmHg. Heart Rate: 60-100 beats per minute.

What is included in an H&P?

In general, the standard physical exam typically includes: Vital signs: blood pressure, breathing rate, pulse rate, temperature, height, and weight. Vision acuity: testing the sharpness or clarity of vision from a distance.

What would a physical examination reveal?

A physical exam is often done as part of a regular checkup, but it can be done at any time. It may be done to: check for possible diseases and medical conditions, including cancer. find medical issues that may become problems in the future.

How do you describe general appearance on a physical exam?

General: Well appearing, well nourished, in no distress. Oriented x 3, normal mood and affect . Ambulating without difficulty. Skin: Good turgor, no rash, unusual bruising or prominent lesions Hair: Normal texture and distribution.

How to explain physical assessment?

Physical examination is the process of evaluating objective anatomic findings through the use of observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient's history and pathophysiology.

How to present physical examination findings?

If incorporating examination findings into a presentation, positive and relevant negative findings should be provided rather than recounting the whole examination. Providing the NEWS score and stating which observations are abnormal is good practice. This is especially important for sick patients.

What is included in the physical examination?

In general, the standard physical exam typically includes: Vital signs: blood pressure, breathing rate, pulse rate, temperature, height, and weight. Vision acuity: testing the sharpness or clarity of vision from a distance. Head, eyes, ears, nose and throat exam: inspection, palpation, and testing, as appropriate.

What is the detail description of physical examination?

During a physical examination, a health care provider checks your body to determine if you do or do not have a physical problem. A physical examination usually includes: Inspection (looking at the body) Palpation (feeling the body with fingers or hands)

What are physical examination findings?

A physical examination usually includes: Inspection (looking at the body) Palpation (feeling the body with fingers or hands) Auscultation (listening to sounds, usually with a stethoscope) Percussion (producing sounds, usually by tapping on specific areas of the body)

For pdfFiller’s FAQs

What is Physical Examination Record?

A Physical Examination Record is a document used to document the results of a physical examination performed by a qualified healthcare professional, typically to assess an individual's health and fitness.

Who is required to file Physical Examination Record?

Individuals or organizations such as employers, schools, or sports teams may be required to file a Physical Examination Record for participants or employees as part of compliance with health regulations or safety standards.

How to fill out Physical Examination Record?

To fill out a Physical Examination Record, a healthcare professional must complete sections detailing the patient's health history, perform a physical examination, and record findings including vital signs, assessments, and any other relevant health indicators.

What is the purpose of Physical Examination Record?

The purpose of a Physical Examination Record is to provide an official account of an individual's health status, facilitate medical care, ensure compliance with health regulations, and support decision-making regarding fitness for activities or employment.

What information must be reported on Physical Examination Record?

The information that must be reported on a Physical Examination Record typically includes personal details of the individual, medical history, results of the physical examination, vital signs, immunization status, and any recommendations or follow-up needed.