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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