Revised: 05/19/2020
Allied Health Physical Exam Form (to be filled out
by the physician)
TO BE COMPLETED BY PHYSICIAN:
Temp: _ Pulse: Resp: B/P: __ Ht: Wt:
General Appearance:
Skin: Mucous Membranes:
Eyes: Pupils: Fundus:
Visual Acuity: Color Vision:
Ears: __ ____ Hearing: _ Nose: Throat:
Chest: Abdomen:
Heart: Lungs:
Extremities: ROM:
Lymph Nodes: Neck Axilla Inguinal Abdominal
Reflexes:
Check Box Below OR Specify Any Restrictions:
I have found no evidence to indicate the student has any physical restrictions related to lifting (up to
50 lbs.), transferring (up to 100 lbs.), gait, bending/stooping/kneeling, standing (12 hrs.), reaching, manual
dexterity, or balance or any health condition that would create a hazard to self, patients, or others.
Student has the following restrictions:
___________________________________________________________________________________
___________________________________________________________________________________
Restrictions are due to: ________________________________________________________________
If restriction is related to pregnancy, estimated date of delivery is: ______________________________
Physician: ___ NPI Number: ________________
Signature (required) (required)
___________________________
Date:
Type or Print Name (required)
Last Name First Name
Date of Birth
click to sign
signature
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