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Patient History
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Any disorder of the heart or blood vessels?
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If yes, explain:
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Disease of the stomach/liver/intestines/rectum
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If yes, explain:
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Disorder of the prostate/bladder/kidneys/genito
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If yes, explain:
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Anything else, e.g., cancer, cyst or tumor.....
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If yes, explain:
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On examination, abnormality of the following
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Head, eyes, ears, nose, mouth, pharynx?
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If yes, explain:
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Skin (incl. scars) lymph nodes, varicose veins
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If yes, explain:
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Nervous System include reflexes, gait, paralysis
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If yes, explain:
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Heart Rate? Heart Rhythm?
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If yes, explain:
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Presence of Heart Murmur?
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If yes, explain:
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Lungs?
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If yes, explain:
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Genitourinary system (by history)?
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If yes, explain:
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Abdomen (include scars)?
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If yes, explain:
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Endocrine system (include thyroid and breasts)?
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If yes, explain:
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Musculoskeletal system (include spine, joints, a
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If yes, explain:
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Prostate Exam (optional)
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Fecal Occult Blood Test (optional)
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Doctor's Notes
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By signing, I acknowledge that I have examined
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