Page 27 - DIDC SOPS and Guidelinesv as of April 2019

Basic Medical Examination Form PMO-6018-01-d

Contingency Released Date
Operations 04/11/18 Page 3 of 4

Name: _____________________________ SS#: __________________________

TO BE COMPLETED BY THE EXAMING PHYSICIAN

HEENT
Eyes Heart Reflexes
Globe NL AB Rhythm NL AB Babinski NL AB
Pupils NL AB Auscultation NL AB Romberg NEG POS
EOM’s NL AB Abdomen NL AB Pupillary Rt NL AB
Lt NL AB
Ears Hernia Accom. Rt NL AB
Canal Clear Y N Umbilical N Y Lt NL AB
TM Visualized Y N Inguinal N Y Biceps Rt NL AB
Scarring of TM Y N Femoral N Y Lt NL AB
Drainage Y N Varicocele N Y Knee Rt NL AB
Nose NL AB Upper Extremity NL AB Lt NL AB
Hands/Fingers NL AB Ankle Rt NL AB
Mouth Legs NL AB Lt NL AB
Teeth NL AB Knees NL AB Proprioception
Throat NL AB Feet/ankles NL AB Up. Ext. Rt NL AB
Skin NL AB Varicosities NL AB Lt NL AB
Neck NL AB Up. Ext. strength NL AB Low. Ext. Rt NL AB
Thyroid NL AB Up. Ext. ROM NL AB Lt NL AB
Lungs NL AB Low. Ext. strength NL AB

Low. Ext. ROM NL AB Sensory Examination:
OPTIONAL: Back/spine ROM NL AB Up. Ext. Rt NL AB
Genitalia NL AB Lt NL AB
SCARS: Neurological Exam Low. Ext. Rt NL AB
Cran. Nerves 2-12: NL AB Lt NL AB

Physician Remarks

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