Medical Doctor Physical Examination Form: Please Have your Doctor Fill This Out And Return It. Fax: 1-310-277-7120

PATIENT NAME: _______________________________________________________________

Address: ______________________________________________________________________

City, State, Zip: ________________________________________________________________

Telephone Number: ( ) ___________________________________________________________

Physical Examination

DATE OF EXAM:___________________

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)