Health Sciences Program (circle one): Medical Lab Science Physician Assistant Physical Therapy



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HEALTH SCIENCES Physical Examination Form

G

Last Name First Name GWid



Email Phone Date of birth (MM/DD/YYYY) Term/Year First Admitted

Health Sciences Program (circle one): Medical Lab Science Physician Assistant Physical Therapy

Physical Exam (Required annually for Health Sciences students engaging in clinical practice)


Age: _____ Height: ______ Weight: _______

Pulse: ______ Blood Pressure: _____/_____ Temp:_______

Vision: Uncorrected: R____/____ L____/____ Both____/____

Corrected: R____/____ L____/____ Both____/____


Normal

Region

Abnormal Findings




Eyes








Ears, Nose, Throat








Mouth, Teeth








Neck








Cardiovascular








Chest, Lungs








Abdomen








Skin








Genitalia








Musculoskeletal








Neuromuscular




Remarkable Medical / Surgical History ________________________________________________________________________________________________________


_______________________________________________________________________________________________________________________________________
Remarkable Family / Social History __________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Allergies ________________________________________________________________________________________________________________________________
Medications _____________________________________________________________________________________________________________________________
GW HEALTH SCIENCES Physical Examination Form (cont’d)


Last Name First Name GWid



Turberculin Skin Test (Mantoux) – Required Annually

Date Placed ____/____/____ Date Read ____/____/____ Result (in mm): ______________

(If positive ONLY) Result of Chest X-Ray: __________ Date of Chest X-Ray : ____/____/____


I certify this student:


  • Has received a physical examination;

  • Is found to be in good health and able to participate in classroom and clinical education components necessary to his/her program of study at the George Washington University.

____________________________________ _______________________ _______________________________________

Health Care Provider Signature or Stamp Date Health Care Provider Phone Number

Health Sciences Students -- Make a copy of the completed form for your own records. Submit BOTH pages of the form to:

GW Student Health Service ∙ ATTN: Health Sciences Student Compliance Program ∙ 2141 K Street, NW, Suite 501 ∙ Washington, DC 20052 ∙ Phone: 202-994-6827 ∙ Fax: 202-973-1572.



GW Student Health Services department will house all physical and immunization information. Upon receipt of this completed form, GW Student Health Services will initiate a tracking sheet to be stored in student’s file with program director or clinical coordinator of program of study.


Revised August 2013

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