Fillable Printable Medical Record Report Of Medical Examination
Fillable Printable Medical Record Report Of Medical Examination
Medical Record Report Of Medical Examination
1. LAST NAME - FIRST NAME - MIDDLE
MEDICAL RECORD
REPORT OF MEDICAL EXAMINATION
DATE OF EXAM
2. IDENTIFICATION NUMBER
3. GRADE AND COMPONENT OR POSITION
4. HOME ADDRESS (Number, street or RFD, city or town, state and ZIP Code) 5. EMERGENCY CONTACT (Name and address of contact)
6. DATE OF BIRTH 7. AGE 8. SEX 9. RELATIONSHIP OF CONTACT
10. PLACE OF BIRTH 11. RACE
12a. AGENCY 12b. ORGANIZATION UNIT 13. TOTAL YEARS GOVERNMENT SERVICE
a. MILITARY b. CIVILIAN
14. NAME OF EXAMINING FACILITY OR EXAMINER, AND ADDRESS 15. RATING OR SPECIALTY OF EXAMINER
16. PURPOSE OF EXAMINATION
17. CLINICAL EVALUATION
NOR-
MAL
ABNOR-
MAL
NOR-
MAL
(Check each item in appropriate column, enter "NE" if not evaluated)
A. HEAD, FACE, NECK AND SCALP
(Check each item in appropriate column, enter "NE" if not evaluated)
B. EARS - GENERAL (INTERNAL CANALS)
(Auditory acuity under items 39 and 40)
C. DRUMS (Perforation)
D. NOSE
E. SINUSES
F. MOUTH AND THROAT
G. EYES - GENERAL
(Visual acuity and refraction under items 28, 29, and 36)
H. OPHTHALMOSCOPIC
I. PUPILS (Equality and reaction)
J. OCULAR MOTILITY (Associated parallel movements nystagmus)
K. LUNGS AND CHEST
L. HEART (Thrust, size, rhythm, sounds)
M. VASCULAR SYSTEM (Varicosities, etc.)
N. ABDOMEN AND VISCERA (Include hemia)
O. PROSTATE (Over 40 or clinically indicated)
P. TESTICULAR
Q. ANUS AND RECTUM (Hemorrhoids, Fistulae) (Hemocult Results)
R. ENDOCRINE SYSTEM
S. G-U SYSTEM
T. UPPER EXTREMITIES (Except feet) (Strength, range of motion)
U. FEET
V. LOWER EXTREMITIES (Except feet) (Strength, range of motion)
W. SPINE, OTHER MUSCULOSKELETAL
X. IDENTIFYING BODY MARKS, SCARS,TATTOOS
Y. SKIN, LYMPHATICS
Z. NEUROLOGIC (Equilibrium tests under item 41)
AA. PSYCHIATRIC (Specify any personality deviation)
BB. BREASTS
CC. PELVIC (Females only)
NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 42 and use additional sheets if necessary)
REMARKS AND ADDITIONAL DENTAL
DEFECTS AND DISEASES
A. URINALYSIS: (1) SPECIFIC GRAVITY
(2) URINE ALBUMIN
(3) URINE SUGAR
C. SYPHILIS SEROLOGY (Specify test used
and results)
(4) MICROSCOPIC
D. EKG
E. BLOOD TYPE AND HR
FACTOR
B. CHEST X-RAY OR PPD (Place, date, film number and result)
NSN 7540-00-634-6038
88-126
Designed using Perform Pro, WHS/DIOR, Jan 97
STANDARD FORM 88 (Rev. 10-94) (EG)
Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
18. DENTAL (Place appropriate symbols, show in examples, above or below number of upper and lower teeth.)
0
1 2 3
32 31 30
0
Restorable
Teeth
Non-
restorable
Teeth
Missing
Teeth
Replaced
by
Dentures
Fixed
Partial
Dentures
( X )
1 2 3
32 31 30
( X )
/
1 2 3
32 31 30
/
X
1 2 3
32 31 30
X
X X X
1 2 3
32 31 30
X X X
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
R
I
G
H
T
L
E
F
T
ABNOR-
MAL
FEMALE MALE
WHITE BLACK
AMERICAN INDIAN/
ALASKA NATIVE
HISPANIC
WHITE
HISPANIC
BLACK
ASIAN/PACIFIC
ISLANDER
F. OTHER TESTS
19. TEST RESULTS (Copies of results are preferred as attachments)
NAME IDENTIFICATION NO. OF SHEETS ATTACHED
MEASUREMENTS AND OTHER FINDINGS
20. HEIGHT 21. WEIGHT 22. COLOR HAIR 23. COLOR EYES 24. BUILD 25. TEMPERATURE
26. BLOOD PRESSURE (Arm at heart level)
A.
SITTING
SYS.
DIAS. DIAS.
SYS.
DIAS.
SYS.
B.
RECUM-
BENT
C.
STANDING
(5 MINS.)
27. PULSE (Arm at heart level)
A. SITTING B. RECUMBENT C. STANDING (3mins.) D. AFTER EXERCISE E. 2 MINS. AFTER
28. DISTANT VISION
RIGHT 20/
LEFT 20/
CORR. TO 20/
CORR. TO 20/
29.REFRACTION
BY
BY
S.
S.
CX
CX
30. NEAR VISION
CORR. TO
CORR. TO
BY
BY
31. HETEROPHORIA (Specify distance)
ESO
EXO
R.H. L.H. PRISM DIV.
PRISM CONV.
CT
PC PD
32. ACCOMMODATION
RIGHT
RIGHT
LEFT
LEFT
35. FIELD OF VISION
39. HEARING
33. COLOR VISION (Test used and result)
36. NIGHT VISION (Test used and result)
34. DEPTH PERCEPTION
(Test used and score)
37. RED LENS TEST
UNCORRECTED
CORRECTED
38. INTRAOCULAR TENSION
RIGHT LEFT
RIGHT W/V
LEFT W/V
/15SV
/15SV
/15
/15
40. AUDIOMETER
RIGHT
LEFT
250
256
500
512
1000
1024
2000
2048
3000
2896
4000
4096
6000
6144
8000
8192
41. PSYCHOLOGICAL AND PSYCHOMOTOR (Tests used and score)
42. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY
43. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers)
44. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify)
45A. PHYSICAL PROFILE
P
U
L
H
E
S
A
B
C
E
45B. PHYSICAL CATEGORY
46. EXAMINEE (Check)
47. IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS BY ITEM NUMBER
48. TYPED OR PRINTED NAME OF PHYSICIAN
49. TYPED OR PRINTED NAME OF PHYSICIAN
SIGNATURE
SIGNATURE
SIGNATURE
SIGNATURE
50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which)
51 TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY
A
B
IS QUALIFIED FOR
IS NOT QUALIFIED FOR
STANDARD FORM 88 (REV. 10-94)
SLENDER MEDIUM HEAVY OBESE
(Use additional sheets if necessary)
