Physical Exam Form - National Institutes of Health
|STUDY NAME |
|Site Number: | |Visit Date: |__ __ / __ __ __ / 2 0 __ __ |
| |________________ | |d d m m m y y y y |
|Pt_ID: | | | |
| |________________ | | |
| Visit Type (circle one): |Screening | Visit 2 |Visit 5 |
| |Baseline |Visit 3 |Completion Visit |
| |Visit 1 |Visit 4 | |
|CATEGORY |Normal |IF Abnormal, Describe below |Change from baseline |
| |Or Abnormal | | |
| |Normal | |Yes |
|General Appearance |Abnormal | |No |
| |Not Examined | |NA |
| |Normal | |Yes |
|HEENT |Abnormal | |No |
| |Not Examined | |NA |
| |Normal | |Yes |
|Neck |Abnormal | |No |
| |Not Examined | |NA |
| |Normal | |Yes |
|Chest and Lungs |Abnormal | |No |
| |Not Examined | |NA |
| |Normal | |Yes |
|Cardiovascular |Abnormal | |No |
| |Not Examined | |NA |
|Abdomen |Normal | |Yes |
| |Abnormal | |No |
| |Not Examined | |NA |
| |Normal | |Yes |
|Genitourinary |Abnormal | |No |
| |Not Examined | |NA |
| |Normal | |Yes |
|Rectal |Abnormal | |No |
| |Not Examined | |NA |
| |Normal | |Yes |
|Musculoskeletal |Abnormal | |No |
| |Not Examined | |NA |
|Lymph Nodes |Normal | |Yes |
| |Abnormal | |No |
| |Not Examined | |NA |
|Extremities/Skin |Normal | |Yes |
| |Abnormal | |No |
| |Not Examined | |NA |
|Neurological |Normal | |Yes |
| |Abnormal | |No |
| |Not Examined | |NA |
|Other:__________ |Normal | |Yes |
| |Abnormal | |No |
| |Not Examined | |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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