Medical History and Physical Examination Form
1 Elizabeth Pl, Suite NWB40, Dayton, OH 45417
Patient Name
*
First Name
Middle Name
Last Name
Date of Exam
*
/
Month
/
Day
Year
Date
Gender
*
Male
Female
Date of Birth
*
/
Month
/
Day
Year
Date
Patient Address
Street Address
Street Address Line 2
City
State
Zip Code
Height
Weight
B/P
P
Current Medications
Allergies
*
Penicillin
Aspirin
Sulfa
Codeine
No known allergies
Other Allergies:
Major Illnesses
Past Surgeries
General Appearance
PHYSICAL EXAMINATION
Normal: YES or NO
YES
NO
Appearance, skin
Eyes
Ears, nose, mouth/throat, neck
Lungs
Heart, pulses
Normal: YES or NO
YES
NO
Abdomen, pelvis
Neurological
Ortho, spine, extremities
Mental Health
Abnormal Findings:
Physician’s Signature:
Clear
Physician Name:
Date
/
Month
/
Day
Year
Date
Submit
Print Form
Should be Empty: