Fillable Physical Exam STUDY NAME Visit Type (circle one): (National Institutes of Health)

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Physical Exam STUDY NAME Visit Type (circle one): (National Institutes of Health)

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Physical Exam
Physical Exam 1 of 1 Version 1.0
STUDY NAME
Site Number:
Pt_ID:
________________
________________
Visit Date:
__ __ / __ __ __ / 2 0 __ __
d d m m m y y y y
Visit Type (circle one): Screening
Baseline
Visit 1
Visit 2
Visit 3
Visit 4
Visit 5
Completion Visit
CATEGORY
NORMAL
OR ABNORMAL
IF ABNORMAL, DESCRIBE BELOW
CHANGE FROM
BASELINE
General Appearance
Normal
Abnormal
Not Examined
Yes
No
NA
HEENT
Normal
Abnormal
Not Examined
Yes
No
NA
Neck
Normal
Abnormal
Not Examined
Yes
No
NA
Chest and Lungs
Normal
Abnormal
Not Examined
Yes
No
NA
Cardiovascular
Normal
Abnormal
Not Examined
Yes
No
NA
Abdomen
Normal
Abnormal
Not Examined
Yes
No
NA
Genitourinary
Normal
Abnormal
Not Examined
Yes
No
NA
Rectal
Normal
Abnormal
Not Examined
Yes
No
NA
Physical Exam
Physical Exam 2 of 2 Version 1.0
Musculoskeletal
Normal
Abnormal
Not Examined
Yes
No
NA
Lymph Nodes
Normal
Abnormal
Not Examined
Yes
No
NA
Extremities/Skin
Normal
Abnormal
Not Examined
Yes
No
NA
Neurological
Normal
Abnormal
Not Examined
Yes
No
NA
Other:__________
Normal
Abnormal
Not Examined
Yes
No
NA
Note: For follow-up PE, if a body system category changes from “Normal” at baseline to “Abnormal” at follow-up due to a
new disease/condition, or a preexisting disease/condition worsens from the baseline, an adverse event form should be
completed to report the change.
PHYSICIAN SIGNATURE: ___________________________ DATE SIGNED ___ ___ / ___ ___ ___ / 2 0 ___ ___
d d m m m y y y y
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Completed 19 July 2020

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