Doctor Exam Form

Physical Examination DATE OF EXAM:____________________________________________________________________

PATIENT NAME: ___________________________________________________________________

Address: ________________________________________________________________________

City, State, Zip: ___________________________________________________________________

Telephone Number: ( ) _____________________________________________________________

Date of Birth: _________________

Age: _________ __

Sex: M F

Blood Pressure: ______________

Weight: ______________

Height: _______________

Physical Exam Normal Abnormal General _____________________________ ________________ ___________________ HEENT_______________________________ ________________ ___________________ Neck________________________________ ________________ ___________________ Chest_______________________________ ________________ ___________________ Cor_________________________ ________________ ___________________ Abdomen ____________________________ ________________ ___________________ Impression:__________________________________________________________________

Allergies including medications: ___________________________________________________________________

Current medications including Over The Counter. Name, Strength and Dosage:

____________________________________________________________________

Physician Signature: _____________________ M.D. Date: _______________________________

Physician Name: ______________________________________________________________________

Address: _____________________________________________________________________________

Telephone: ( ) __________________________

Laboratory Studies Required to Accompany this Examination:

-Complete Blood Count, DIFF, PLTS

-Comprehensive Metabolic Screen

-Comprehensive Lipid Panel

-Comprehensive Thyroid Panel (TSH, T3U, T4)