Physical Examination Form

PHYSICAL EXAMINATION FORM

WPI Health and Wellness Services p.508-831-5520 f. 508-831-5953

Name: ____________________________________________Date of Birth: ______________Date of Exam: ___________________________

Does applicant have any past/current medical problems? ___YES ___ NO Gender: _________ Preferred Gender Pronoun: __________

If yes, please describe: ________________________________________________________________________________________________

Does the applicant have a history of past/current emotional or psychological problems? ___YES ___NO

If yes, please describe: ________________________________________________________________________________________________

Has applicant been hospitalized in the past? ___YES ___ NO

If yes, please describe: _____________________________________________________________________________________________

List Pertinent Family History: ________________________________________________________________________________________

Current Medication(s) with dosage: ___________________________________________________________________________________

Allergies: (medication, food, or other):_________________________________________________________________________________

Height________ Weight________ BMI ________ Pulse________ BP _______/_______ Vision R 20/______ L 20/_______

· The patient may fully participate in physical education and club sports. ___YES ___ NO

*** If NO, please list restrictions._______________________________________________________________________________________

· Does the patient require additional follow up? . ___YES ___ NO

*** If YES, please provide treatment plan. ________________________________________________________________________________

________________________________________________________________________________________________________________

(Submit additional information as necessary.)

Healthcare provider: _______________________________________________________________________________________________

Print Last Name, First Name, NP/ PA/ MD/DO

Address_________________________________________________________________________________________________________

Phone #: ______________________________________________________ Fax #: ____________________________________________

Signature of Healthcare Provider:

________________________________________________________________________________________________________________

Date