Fillable Printable VA Form 0927c
Fillable Printable VA Form 0927c
VA Form 0927c
OMB Number: 2900-0759
Respondent Burden: 13 minutes
PARTICIPANT REGISTRATION FORM -- PHYSICAL EXAM
NATIONAL VETERANS TEE TOURNAMENT
(To be completed by a Clinician. Please type or print clearly)
PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17,
Section 1710. VA may disclose the information that you put on this form as permitted by law. VA may make a "routine use"
disclosure of the information as outlined in the Privacy Act systems of records notices identified as 121VA19 “National Patient
Databases - VA”. Providing the requested information is voluntary. However, you will not be able to participate in the event without
furnishing this information.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in
accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor,
and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who must complete this application will average 13 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the forms.
Dear Examining Clinician: Your patient is planning to participate in a three-day event with moderately strenuous, sporting activities,
provided that you concur. To ensure that this is an appropriate activity for this Veteran, please conduct a detailed review of his/her
medical record. Thank you for assisting us in ensuring this participant's safety.
PATIENT'S NAME SOCIAL SECURITY
NUMBER (Last 4 digits only)
DATE
PRIMARY DISABILITY/DIAGNOSIS: DATE OF ONSET
VISUALLY IMPAIRED
LEGALLY BLIND TOTALLY BLIND RESIDUAL VISION
SPINAL CORD INJURY (SCI)
- LEVEL
COMPLETE INCOMPLETE
PARAPLEGIC
QUADRIPLEGIC
MULTIPLE SCLEROSIS (MS)
HEAD INJURY
CVA WITH RESIDUAL
AMPUTEE
RIGHT LEG, A/K, B/K RIGHT ARM, A/E, B/E OTHER
LEFT LEG, A/K, B/K LEFT ARM, A/E, B/E
PSYCHOLOGICAL CONDITIONS
PTSD ANXIETY DEPRESSION SEIZURES STROKE
OTHER CONDITION(S)
PLEASE RATE YOUR PATIENTS LEVEL OF INDEPENDENCE
INDEPENDENT ONCE ORIENTED
NEEDS SIGHTED GUIDE OCCASIONALLY AFTER ORIENTATION
NEEDS SIGHTED GUIDE CONTINUOUSLY
PATIENT NEEDS
PATIENT REQUIRES ATTENDANT?
YES
NO
IF YES, ATTENDANTS' NAME
USES WHEELCHAIR MAJORITY OF TIME?
YES NO
USES OTHER ADAPTIVE EQUIPMENT?
YES NO
IF YES, WHAT
VA FORM
FEB 2014
0927c
PATIENT'S NAME
SOCIAL SECURITY NUMBER
(Last 4 digits only)
MEDICAL HISTORY (i.e., diabetes, heart disease, hypertension, respiratory difficulty)
LIST ALL MEDICATIONS, INCLUDING ASPIRIN AND OTHER "OVER THE COUNTER" MEDICINE/SUPPLEMENTS
KNOWN ALLERGIES
DATE OF LAST TETANUS SHOT
IS THE PATIENT TAKING COUMADIN
OR OTHER ANTICOAGULANTS?
YES NO
IF YES, WHICH
DOES THE PATIENT SMOKE?
YES NO
ALCOHOL OR OTHER SUBSTANCE USE?
YES NO
PHYSICAL EXAM
HEIGHT
(inches)
WEIGHT
(pounds)
PULSE
CARDIAC BLOOD PRESSURE
HEAD & NECK PULMONARY
ABDOMEN EXTREMITIES
HEENT NEURO
OTHER FINDINGS
IN MY OPINION, THE ABOVE INDIVIDUAL:
IS MEDICALLY FIT TO PARTICIPATE IS NOT MEDICALLY FIT TO PARTICIPATE
SIGNATURE OF EXAMING CLINICIAN NAME OF EXAMING CLINICIAN (Please print)
ADDRESS OF EXAMINING CLINICIAN TELEPHONE NUMBER
VA FORM 0927c, FEB 2014, page 2
