Med Exam Form - Kent County Arc - Trudeau Center

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Medical Examination Form

Last Name:______________________

First:______________

Middle Init._____

DOB___/___/___

Sex __

Sex______

Address:__________________________________________________________________________
City:___________________________	State:_______	Zip Code:__________

Height: _____________

Weight: ____________

Blood Pressure:______________

Eyes: ____________
(condition, normal, corrected)

Ears: ______________________________________ (normal, needs attention, RX)	Nose: ___________________________________ (obstruction, chronic sinus, etc.)
Throat: ____________________________________ (tonsils: normal, enlarged, removed)	Neck: ___________________________________ (thyroid enlargement, nodules, etc.)
Mouth: _____________________________________ (caries abnormalities)	Breast: __________________________________ (abnormalities, etc. )
Lymphatic System: ___________________________ (cervical inguinal, etc)	Abdomen:________________________________ (scars, abdominal, etc.)
Heart: ______________________________________ (dyspnea, cyanosis, edema etc.)	Hernia: __________________________________ ( inguinal, abnormal, etc.)

Male: Genito-Urinary: ______________________________________________________________________
(urethral discharge, enlarged prostate, etc.)

Female: Gynecological: _____________________________________________________________________
(prolapsed, cytocele, rectocele, cervix )

Pap smear: ____________________________ Recommendations:___________________________________

Ano-rectal: ______________________________________________________________________________
(hemorrhoids, prolapsed, growths, etc.)

Varicosities: _____________________________________________________________________________

Nervous / Emotional Evaluations: (i.e.: paralysis, speech, gait, peculiar habits or behavior, moods)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Laboratory: Urinalysis ( lab’y stick acceptable):

Occult Blood: ______________ Albumin: __________________ Sugar:_______________
Blood Glucose: _____________ Hepatitis- B Screening:_________ HGB:______________

Authorization for Physical Therapy Evaluation? Yes_________ No _________
Specific Reason:
_______________________________________________________________________________________
_______________________________________________________________________________________

Orthopedic Impairments: (describe)

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Diagnosis: Major__________________________________________________________________________________
_______________________________________________________________________________________
Minor: _________________________________________________________________________________
Prognosis:
_______________________________________________________________________________________
Recommendations:
Are further tests advisable for diagnosis, prognosis, or treatment?
If yes specific type:
_______________________________________________________________________________________
_______________________________________________________________________________________

Are there any restrictions for working conditions? (standing for long periods, lifting, allergies etc.)
_______________________________________________________________________________________
_______________________________________________________________________________________
                Are there any restrictions for Recreational Activities?
_______________________________________________________________________________________
Medication: Is the patient under medication? ____________________________
Twenty –Four hour medication regime:

Medication                                     Dosage                Time                   Purpose
_________________________           _______________ _____________    __________________
_________________________           _______________ _____________    __________________
_________________________           _______________ _____________    __________________
_________________________           _______________ _____________    __________________
_________________________           _______________ _____________    __________________
Order for adverse reactions:
________________________________________________________________________________

Any known allergies? _______________________________________________________________

Medications may be administered by authorized personnel at the facility. ________________________
Client may ______________   May not ______________ participate in Trudeau Recreation Programs.


      _____________________________________                      ______________________
      Physicians Signature                                                                  Date

      Physician name & address (printed please)

      ________________________________________________

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