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THE HEBREW UNIVERSITY OF JERUSALEM Roth berg International School Boar Building, Mount Scopus 91905 Jerusalem, Israel REPORT OF MEDICAL EXAMINATION TO THE EXAMINING PHYSICIAN Your health evaluation

How to fill out report of medical examination

How to fill out a report of medical examination:

1. Begin by carefully reading the instructions provided with the report. Familiarize yourself with the required format and any specific details that need to be included.
2. Start by filling out the basic information section. This typically includes details such as the patient's name, date of birth, address, contact information, and relevant identification numbers (e.g., healthcare or insurance ID).
3. Record the date and time of the examination. This is crucial for documenting the timeline of the medical evaluation.
4. Document the reason for the medical examination. Describe the symptoms, complaints, or medical condition that necessitated the evaluation. Be clear and concise in your description, providing objective information about the patient's condition.
5. Include a comprehensive medical history. This involves detailing any pre-existing medical conditions, previous surgeries, allergies, medications currently taken, and any family history of relevant diseases or conditions. Thoroughly gather all the necessary information from the patient or their medical records.
6. Document the physical examination findings. This includes recording vital signs, such as blood pressure, heart rate, temperature, and respiratory rate. Note any abnormalities or significant observations during the examination, such as swelling, discoloration, or range of motion limitations.
7. If applicable, document any laboratory tests, imaging studies, or diagnostic procedures conducted as part of the medical examination. Include the test name, date, and any relevant results or findings.
8. Provide a clear and concise summary of the examination. This should include the primary findings, diagnosis if available, and any recommendations or follow-up instructions. Use objective language and avoid speculation or personal opinions.
9. Sign and date the report. As the healthcare professional responsible for conducting the examination, your signature confirms the accuracy and validity of the information provided. In some cases, additional signatures from supervising physicians or medical directors may be required.

Who needs a report of medical examination?

1. Employers: Certain jobs require candidates to undergo a medical examination to ensure they meet the physical and mental requirements of the position. Employers use these reports to evaluate a candidate's fitness for work and determine if any accommodations or restrictions are necessary.
2. Insurance companies: When applying for certain types of insurance, such as life, health, or critical illness insurance, individuals may need to undergo a medical examination. The report helps insurers evaluate the individual's health and assess the risks involved in providing coverage.
3. Legal purposes: In legal matters such as personal injury claims or workers' compensation cases, medical examination reports can play a crucial role. They provide an objective assessment of the claimant's injuries or condition and help determine the extent of damages or compensation owed.
4. Healthcare providers: The report of a medical examination serves as a crucial document for healthcare providers, aiding in the continuity of care. It provides essential information about a patient's medical history, examination findings, and potentially assists in diagnosis and treatment planning.

In summary, filling out a report of medical examination entails following the provided instructions, documenting relevant information about the patient's medical history, conducting a thorough physical examination, and summarizing the findings. Various entities, including employers, insurance companies, legal parties, and healthcare providers, may require these reports for different purposes.

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