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Physical Examination Form

Explore Our Mental Heath and Addiction Treatment Center in Raleigh, ND

Part I: To Be Completed by Resident

Name(Required)
MM slash DD slash YYYY
Address
Gender(Required)

Immunizations

Covid Testing
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

Tuberculosis (TB)

MM slash DD slash YYYY

Part II: General Physical Examination (completed by medical provider)

Vital Signs

Evaluation of Systems

Eyes/Ears/Nose
Normal Findings?
Mouth/Throat
Normal Findings?
Head/Face/Neck
Normal Findings?
Lungs
Normal Findings?
Cardiovascular
Normal Findings?
Extremities
Normal Findings?
Gastrointestinal
Normal Findings?
Musculoskeletal
Normal Findings?
Integumentary
Normal Findings?
Endocrine
Normal Findings?
Nervous System
Normal Findings?

Addiction Comments

Withdrawal symptoms
CoVid symptoms
Limitations Or Restrictions For Activities