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OCFS-1453 (10/2002) NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES HEALTH SERVICES PHYSICAL EXAMINATION (Place Youth Label Here) YOUTH NAME: DATE: DATE OF BIRTH: SEX: MALE FEMALE ETHNICITY: HEIGHT: FT INCHES WEIGHT: LBS. BP: / TEMP: PULSE: RESPIRATION: CHECK indicates a normal finding or the absence of abnormality. Make no mark if no observation is made. CIRCLE abnormalities and describe in detail. INTEGUMENT: Skin Track Marks Hair Acne Nails Abscesses Scars Rashes HEAD: EYES: Lids Lens Pupils Fundi EOM’s Sclera Conjunctiva Visual Acuity EARS, NOSE, THROAT: Pinna Lips Canals Teeth & gums Drums Tongue Gross hearing Mucosa Pure Tone Tonsils-pharynx Hearing Screen Breath NECK: Motion Veins Trachea Masses Thyroid NODES: CERVICAL SUPRACLAVICULAR OCCIPITAL AXILLARY EPITROCHLEAR INGUINAL R L CHEST: Shape BREASTS Masses Nipples ---PAGE BREAK--- OCFS 1453 (10/2002) LUNGS Percussion Fremitus Breath sounds Adventitious sounds HEART: Point of maximal impulse (position, quality) rate S1 S2 S3 S4 A2 P2 Other extra sounds murmurs rubs PULSES: CAROTID BRACHIAL RADIAL FEMORAL POPLITEAL D.P./P.T. R L ABDOMEN: Shape Masses Bowel sounds Hernias Tenderness Liver Spleen Kidneys RECTUM (only if clinically indicated, not in screening exam): Sphincter tone Masses Stool GENITALIA: MALE FEMALE Penis Perineum-vagina Testes Cervix Prostate Uterus Circumcised Adnexa Y N Pap taken Foreskin Y N Tanner stage: ---PAGE BREAK--- OCFS 1453 (10/2002) BACK Scoliosis Spinal Tenderness CVA Tenderness BONES, JOINTS, EXTREMITIES: Deformities Limitation of motion Edema Inflammation Varicosities Tenderness Weakness NERVOUS SYSTEM Cranial Nerves Speech Motor: Gait Coordination Deep Tandon Reflexes Sensory PinPrick Position Vibratory SUMMARY COMMENTS: Please note below any condition that would limit physical activity or participation in contact sports and/or strenuous activities, any condition requiring special diet and the diet required, and any problem that requires special services or consultation. Examined By: (Signature) Title: Date: / / Name: (Please Print): Telephone: (Area Code, Number) ( ) - Office/Clinic Name: Address