19
III. MEDICAL ASSESSMENT
Height_________ Weight__________ Blood Pressure __________ Resting Heart Rate__________
ITEM MEDICAL
COMPONENTS NORMAL ABNORMAL REMARKS
1 General
Appearance
2
Head, Neck, Face & Scalp
3
Nose & Sinuses
4
Mouth & Throat
5
Teeth & Gums
6 Ears
7 Eyes
8 Lungs
9 Breasts
10 Heart
11 Vascular--Include
Varicosities
12 Abdomen--Include
Hernia
13 Ano-rectal
14 Endocrine--Including
Thyroid
15 Genitalia
16 Upper
Extremities
17 Lower
Extremities
18 Spine
19 Skin
&
Hair
20 Neurological
21 Lymph
Nodes
22 Psychological
Laboratory:
Hgb/Hct:_________________________________ UA:__________________________
Other blood studies?
Yes (please describe)_________________________________________ No_____
IV. PHYSIOLOGICAL DATA:
GRADED EXERCISE TEXT: Protocol:___________________ HR (rest): _____ BP (rest):_____
PWC (max METs) Observed:________ VO
2
max___________ HR (rest): _____ BP (rest):_____
PWC (max METs) Predicted:________ VO
2
max___________ HR (rest): _____ BP (rest):_____
CONCLUSION:____________________________________________________________________
PULMONARY FUNCTION TESTS: ___________________________________________________
HYPOXIC VENTILATORY RESPONSE: _______________________________________________
OTHER:___________________________________________________________________________
V. PSYCHOLOGICAL EVALUATION
PSYCHO-PHYSIOLOGIC
STRESS
ASSESSMENT:
1. Serial 7 Subtraction Test:
BP before:________
BP after:_________
HR
before:________ HR
after:_________
2. Cold Pressor Test:
BP before:________
BP after:_________
HR
before:________ HR
after:_________
INTERVIEW AND SUMMARY: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
