Date of exam __________
Enter the date of the physical exam in the format DD/MMM/YYYY.
Height _______ m
Enter the participant’s height in meters. Enter height in the “NNN.NN” format. This format allows up to three digits prior to the decimal and up to two digits after the decimal.
Weight _______ kg
Enter the participant’s weight in kilograms. Enter weight in the “NNN.NN” format. This format allows up to three digits prior to the decimal and up to two digits after the decimal.
BMI _______ (calculated)
The system will generate an answer based off of height and weight. BMI calculation = weight (kg) / height (m) 2. This field requires no response from the study site and cannot be edited.
Systolic blood pressure (expected range 50-100 mmHg) _______
Enter the participant’s systolic blood pressure in mmHg. Enter the systolic blood pressure in the “NNN” format. This format allows up to three digits without a decimal. (Expected range: 50 – 200 mm Hg).
Diastolic blood pressure (expected range 20 – 125 mmHg) _______
Enter the participant’s diastolic blood pressure in mmHg. Enter the diastolic blood pressure in the “NNN” format. This format allows up to three digits without a decimal. (Expected range: 50 – 200 mm Hg).
Body Systems
General appearance
Indicate if there are any general appearance abnormalities present at the time of the physical exam. If general appearance was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Skin
Indicate if there are any skin abnormalities present at the time of the physical exam. If skin was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Eyes
Indicate if there are any eye abnormalities present at the time of the physical exam. If eyes was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Ear, nose and throat
Indicate if there are any ear, nose, and throat abnormalities present at the time of the physical exam. If ear, nose, and throat was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Head and neck
Indicate if there are any head and neck abnormalities present at the time of the physical exam. If head and neck was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Cardiovascular
Indicate if there are any cardiovascular abnormalities present at the time of the physical exam. If the cardiovascular system was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Chest and lungs
Indicate if there are any chest and lung abnormalities present at the time of the physical exam. If chest and lungs was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Abdomen
Indicate if there are any abdominal abnormalities present at the time of the physical exam. If abdomen was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Extremities
Indicate if there are any extremital abnormalities present at the time of the physical exam. If extremities were not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Back
Indicate if there are any back abnormalities present at the time of the physical exam. If back was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Lymph Nodes
Indicate if there are any lymph node abnormalities present at the time of the physical exam. If lymph nodes were not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Thyroid
Indicate if there are any thyroid abnormalities present at the time of the physical exam. If thyroids were not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Neurological
Indicate if there are any neurological abnormalities present at the time of the physical exam. If the nervous system was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Musculoskeletal
Indicate if there are any musculoskeletal abnormalities present at the time of the physical exam. If the musculoskeletal system was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
Other body system
Indicate if there are any other body system abnormalities at the time of the physical exam. If any other body system was not examined, answer “Not examined”.
- Normal
- Abnormal
- Not examined
Specify other body system __________
If other body system was examined, specify other body system in the text box.
If abnormal, please specify abnormality __________
If abnormal was indicated, specify abnormality in the text box.
CCG v.1 | CRF v.1
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