Physical Health Exam

Physical Health

Participant ID

_______________________

Name of Assessor

__________________(free type)

Name of Data Clerk

__________________(free type)

Date of assessment

______ (day – 2 digits) ______ (month – 2 digits) __________ (year – 4 digits)

Head/Fontanelle

 Normal

 Normal

 Abnormal (please specify): __________________(free type)

 Abnormal (please specify): __________________(free type)

Ears

Structure

Appears to

hear/responds to

sound

 Yes

 No (please specify): __________________(free type)

Eyes

Structure

 Normal

 Abnormal (please specify): __________________(free type)

Appears to

see/responds to

visual stimuli

 Yes

 No (please specify): __________________(free type)

Skin

Nevi

 No

 Yes (please specify): __________________(free type)

Café au lait

spots

 No

 Yes (please specify): __________________(free type)

Bruising

 No

 Yes (please specify): __________________(free type)

Nose

 Normal

 Abnormal (please specify): __________________(free type)

Mouth and Throat

 Normal

 Abnormal (please specify): __________________(free type)

Teeth

Caries

 No

 Yes (please specify): __________________(free type)

Eruption

 Normal

 Abnormal (please specify): __________________(free type)

Appearance

 Normal

 Abnormal (please specify): __________________(free type)

Lungs

 Normal

 Abnormal (please specify): __________________(free type)

Heart

 Normal

 Abnormal (please specify): __________________(free type)

Femoral pulses

 Normal

 Abnormal (please specify): __________________(free type)

Abdomen

 Normal

 Abnormal (please specify): __________________(free type)

Genitalia

 Normal

 Abnormal (please specify): __________________(free type)

Structure

 Normal

 Abnormal (please specify): __________________(free type)

Male testes

descended

(if applicable)

 Yes

 No (please specify): __________________(free type)

Extremities and Hips

 Normal

 Abnormal (please specify): __________________(free type)

Arthrogryposis

 No

 Yes (please specify): __________________(free type)

Back

 Normal

 Abnormal (please specify): __________________(free type)