Documente Academic
Documente Profesional
Documente Cultură
86
Name:_____________________________
Date of Birth: _______________________
1.Date
2.Temperature
3.Respiratory System
Sputum Analysis
4. Circulatory Sys.
5.Blood Pressure
Pulse
Systolic:
Sitting:
After 3 min.:
Diastolic:
Agility Test:
(Right) Far:
(Right) Far:
Near:
Near:
Blood Analysis
Digestive System
6. Genite
Urinalysis, etc.
7. Skin
8.Loco-motor system
9. Nervous System
10. Eye-conj.,etc
11. Calorie perception
12.Vision without
Glasses
w/ glasses
13. Ears
14. Hearing
Right Ear
(Left) Far:
(Left) Far:
Near:
Near:
Left Ear
15. Nose
16. Throat
17. Teeth and Gum
18. Immunization
Date
19. Remarks
20. Recommendation