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P. Pulse Vision R L 20db HL 25db HL 40db HL Y Response Hearing Welch Allyn / AudioScope Screening Hearing Test IS REQUIRED N No Response Right Ear Left Frequency Hz General HEENT Skin Heart Lungs Abdomen Does patient have hernia Extremities and Back Neurological Other REMARKS M. Student Name SID PHYSICAL EXAMINATION To be completed and signed by a licensed Health Care Provider e.g. physician certified nurse practitioner physician assistant Each section must be completed. Laboratory Reports...

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To be completed and is a form that needs to be filled out.

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To be completed and requires personal and work information of the employee.