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[PDF File]PRE PARTICIPATION PHYSICAL FORM MEDICAL HISTORY …
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MRI, CT, surgery, injections, rehabilitation, physical therapy, a brace, a cast, or crutches? If yes, circle below Head Neck Shoulder Upper arm Elbow Forearm Hand/ Fingers Chest Upper back Lower back Hip Thigh Knee Calf/ Shin Ankle Foot/ Toes 20 Have you ever had a stress fracture?
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[PDF File]Mini-Mental State Examination
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2 Instructions for administration and scoring of the MMSE Orientation (10 points): • Ask for the date. Then specifically ask for parts omitted (e.g., "Can you also tell me what season it
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[PDF File]ANNUAL PHYSICAL EXAMINATION FORM - Health & …
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PHYSICAL EXAMINATION FORM . Name: Date of Exam: Address: Date of Birth: Sex: Male Female DIAGNOSES/SIGNIFICANT HEALTH CONDITIONS CURRENT MEDICATIONS (Attach a second page if needed): Medication Name Dose Frequency Diagnosis Prescribing Physician ... ANNUAL PHYSICAL EXAMINATION FORM
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[PDF File]Date of Birth: Sex: Male (Include a Medical History ...
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Is the person free of communicable diseases? ... Part Two: GENERAL PHYSICAL EXAMINATION Pleasse e accoommpplleette aallll eiinnffoorrmmaattiioonn ttoo avvooiidd rrettuurrnn vviissiittss.. ... Recommendations for manual breast exam or manual testicular exam: ...
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[PDF File]Form I-693, Report of Medical Examination and Vaccination ...
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Form I-693 . OMB No. 1615-0033 Expires 07/31/2022 START HERE - Type or print in black ink. Part 1.€ Information About You€ (To be completed by the person requesting a medical examination, NOT. the civil surgeon) Family Name (Last Name) Given Name (First Name) Middle Name. 2. 3. E. 1. Street Number and Name. Physical Address Other ...
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[PDF File]PREPARTICIPATION PHYSICAL EVALUATION -- MEDICAL …
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PREPARTICIPATION PHYSICAL EVALUATION -- MEDICAL HISTORY REVISED 12-4-14 This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities.These questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.
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[PDF File]ChiLD & ADOLEsCEnThEALT h ExAMinATiOn FORM Print …
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M Physical Exam WNL Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl M M Psychosocial Development M M HEENT M M Lymph nodes M M Abdomen M M Skin M M Language M M Dental M M Lungs M M Genitourinary M M Neurological ... ChiLD & ADOLEsCEnThEALT h ExAMinATiOn FORM NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION Please Print …
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[PDF File]Medical Examination Report Form
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To record results of a driver's physical examination, to determine qualification to operate a commercial motor vehicle (CMV), and ... Report Forms collected by FMCSA will be stored in FMCSA's automated National Registry of Certified Medical Examiners System and will be used to monitor the performance of medi- ... Return to medical exam office ...
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[PDF File]Athletic Physical Form - Printable Business Forms, Sample ...
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athletic physical form, athletic physical exam form, physical exam, physical examination, athletic physical, physical form, athletic, physical Created Date 8/13/2010 9:43:08 AM
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[PDF File]STATE OF FLORIDA Page 1 of 2 School Entry Health Exam
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School Entry Health Exam Page 2 of 2 Name of Child (Last, First, Middle) Birth Date PART II — MEDICAL EVALUATION To be completed and signed by the Health Care Provider ONLY: The child named above has had a complete history and physical exam on the following date: (Exam must be within one year of enrollment) Month Day Year
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Free printable physical exam forms