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Freshmen examines healthily

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Freshmen examines healthily / Physical examination project

 

Health Examination Record

(to be completed by medical personnel)      

Date: Year           Month           Day           

Examiner’s Signature

Height:         cm    Weight:        kg 

Optional Waistline:          cm

 

Blood Pressure:     /     mmHg    Pulse rate:      /min

 

Vision:    Uncorrected: Left           Right             Corrected: Left           Right          

 

Eyes

Normal

Color blindness  Other:         

 

ENT

Normal

Hearing abnormality: Left  Right

Suspected otitis media (further diagnosis required), such as from a perforated ear drum

Swollen tonsils  Earwax embolism  Other:         

 

Head & Neck

Normal

Wry neck (torticollis)  Abnormal mass  Other:         

 

Chest

Normal

Cardiopulmonary disease  Abnormal thorax  Other:         

Abdomen

Normal

Abnormally swollen  Other:         

Spine &

limbs

Normal

Scoliosis  Limb deformity  Bowlegged (Difficulty squatting) 
Other:         

Genitourinary system

Normal

Not checked

Abnormal foreskin  Varicocele  Other:         

 

Skin

Normal

Ringworm Scabies Wart Atopic dermatitis Eczema Other:                                                            

Oral

Normal

Poor oral hygiene    Calculus   Gingivitis    Periodontitis   

Dental malocclusion         Abnormal Oral Mucosa            Other:         

 

 

Dentition status: C-cavity;  X-missing;  ê- filled;  ψ- impacted tooth;  Sp.- supernumerary tooth

C-decayed; X-missing; ê- filled; ψ- impacted tooth; Sp.- Supernumerary tooth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Upper Right

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

  Upper left

Lower Right

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

  Lower Left

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary

 

Normal 

Requires a consultation with a:                                                           

Other:                       

Stamp of hospital/clinic where examination was done

Laboratory Tests

1st

test

Result

Laboratory Tests

1st

test

Result

Abnormal

Follow up

Abnormal

Follow up

Urinalysis

Protein () ()

 

 

 

Blood

lipid

Total cholesterol (mg/dl)

 

 

 

Sugar () ()

 

 

 

Renal

function

Creatinine (mg/dl)

 

 

 

O.B. () ()

 

 

 

UA (mg/dl)

 

 

 

pH

 

 

 

BUN (mg/dl)

 

 

 

Blood

test

Hb (g/dl)

 

 

 

Liver

function

SGOT (U/L)

 

 

 

WBC (103/μL)

 

 

 

SGPT (U/L)

 

 

 

RBC (106/μL)

 

 

 

Hepatitis B

HbsAg

 

 

 

Platelet count (103/μL)

 

 

 

HbsAb

 

 

 

MCV (fl

 

 

 

Other

 

 

 

 

Hct (%)

 

 

 

 

 

 

 

 

Chest

X-ray

Date of X-ray

Result:

No obvious abnormality   R/O TB                     TB-related Calcification                      Abnormal thorax       Pleura cavity edema     Scoliosis                   Cardiomegaly            Bronchiectasis               Other:         

Further treatment, date, and comment:

 

 

Other

tests

Item

Date

Checked by

Result

Referred for follow-up, comment:

 

 

 

 

 

 

 

 

 

 

Summary

Summary of health examination results, for follow-up or treatment, and case management outline

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