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Comprehensive Geriatric Assessment Template
Abdo: stigmata of liver disease, pain, distention, masses, palpable bladder, rectal exam if constipated. Cognitive Testing score: Click or tap here to enter text. Depression Screening Score: Click or tap here to enter text. Reflexes. 0 = no response. 1+ = a slight but definitely present response. 2+ = a brisk response; normal. 3+ = a very brisk ...
blank physical form for employment

[DOC File]Family Practice History and Physical
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NL male/ female exam Endocrine. No thyroid disease or diabetes Rectal. Heme negative, normal prostate Hematologic. No easy bruising or bleeding Lymph. Neck, Axilla, Groin Psychiatric. No h/o anxiety, depression, mental illness MSK. strength 5/5, tone, gait, FROM Allergies: No hayfever, runny nose. Back . neg. SLR test x2, no scoliosis, no spasm
physical exam form word

fitness for duty - Human Resources
Indicate the exact work restrictions which apply to the employee at this time on the chart on the back of this form. (Complete this section if the employee is being released to modified duty.) PHYSICAL EXAMINATIONS FULL. RESTRICTIONS PARTIAL. RESTRICTIONS NO. RESTRICTIONS Sedentary-Lifting 0 to 10 pounds Light-Lifting 10 to 20 pounds
free printable physical exam forms

[DOC File]History and Physical Exam Form - Jim Berg, M.D
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PSA at age 50+, with life expectancy greater than 10 years Testicular Cancer Screening 21-39 yrs. Testicular exam and self-exam instructions as part of the periodic health exam. For Women Only Cervical Cancer Screening Yearly; if three consecutive exams are normal, Pap test may be performed less frequently at discretion of the physician.
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Foster/Adoptive Household Member Physical and Mental ...
In evaluating the individual identified on this form, this agency must be guided by your medical findings, as reported on this form. To meet requirements of being a foster and /or adoptive parent, the applicant(s), as well as all household members , must be in good physical and mental health.
printable history and physical template

[DOC File]source document template - VA Portland
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these templates are for Pis and their study coordinators and should be used as examples or templates to build from and modify to meet their specific needs. Source document templates include inclusion/exclusion worksheet, adverse event tracking log, medications log, missed visit, early withdrawal form, study visit form, randomization form, study procedures form, physical evaluation form ...
physical examination forms

[DOT File]DHS-381, Well Child Exam Middle Childhood: 6-10 Years
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A physical exam, including developmental, psychosocial, and behavioral health screening, must be completed utilizing all Early and Periodic Screening. Diagnostic, and Treatment (EPSDT) requirements. Please attach the completed physical form utilized at this visit.
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[DOC File]LOWER EXTREMITY EXAM – (ANKLE/FOOT)
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Title: LOWER EXTREMITY EXAM – (ANKLE/FOOT) Author: Parker Last modified by: Parker Created Date: 1/19/2010 1:11:00 PM Company: HNS Other titles: LOWER EXTREMITY EXAM – (ANKLE/FOOT)
physical examination template pdf

[DOCX File]Child Adolescent Diagnostic Assessment.cdr
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Date of Last Physical Exam ... (Complete the Mental Status Examination form or provide a thorough written narrative below. If AoD client, include ODADAS MSE elements: appearance, attitude, motor activity, affect, mood, speech, and thought content.) ...
blank physical form for employment

NAME [Patient Name] - Word Templates - Hundreds of Free ...
Risk factors and disease prevention; RISK FACTORS REVIEWED. Diet. Exercise. Safety (seat belts, smoke detectors, firearms, violence) Smoking. Alcohol and other drugs
physical exam form word

Free physical exam form template