Physical Examination
Date of Assesment
date
[different findings should be separated by either a (:) or a (/)]
text
1.Hair and skin
text
2.Lymph nodes
text
3.Eyes
text
4.Ears, Nose and Throat
text
5.Breasts
text
6.Respiratory
text
7.Cardiovascular
text
8.Abdomen
text
9.Urogenital
text
10.Pelvic
text
11.Rectal
text
12.Musculoskeletal
text
13.Neurological
text
14.Mental Status
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1 Hair and Skin 2 Lymph Nodes 3 Eyes 4 Ears, Nose and Throat 5 Breasts 6 Respiratory 7 Cardiovascular 8 Abdomen 9 Urogenital 10 Pelvic 11 Rectal 12 Musculoskeletal 13 Neurological 14 Mental Status
text
Urine Drug, Alcohol and Cotinine Screen
Date of sample taken
date
Time of sample taken
time
Mark appropriate box(es):
text
Cocaine
integer
Amphetamines
integer
Benzodiazepines
integer
Cannabinoids
integer
Opiates
text
Barbiturates
integer
Alcohol
integer
Cotinine
integer
If any of the above are positive, exclude subject from the study.
text
Serology
Date sample taken
date
Mark appropriate boxes:
text
HIV antibody
integer
Hepatitis B surface antigen
integer
Hepatitis C antibody
integer
If any of the above are positive, exclude subject from the study.
text
Vital Signs
Date
date
Time
time
Height
integer
Weight
float
Body mass index
float
Semi-supine
integer
Semi-supine
integer
Heart rate
integer
Temperature
float
Respiration rate
integer
12-lead ECG (Semi-Supine)
Start Date of ECG
date
Start Time of ECG
time
Ventricular Rate
integer
PR Interval
integer
QRS Duration
integer
Uncorrected QT Interval
text
QTc Interval
integer
mark one:
text