Medical History and Physical Examination Form

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

Appearance, skin

Eyes

Ears, nose, mouth/throat, neck

Lungs

Heart, pulses

Normal: YES or NO

YES

Abdomen, pelvis

Neurological

Ortho, spine, extremities

Mental Health