Physical Exam STUDY NAME Site Number PtID

Physical Exam STUDY NAME Site Number PtID

DESCARGAR PDF

Physical Exam
STUDY NAME
Site Number:
Pt_ID:
________________
________________
Visit Date:
__ __ / __ __ __ / 2 0 __ __
d d m m m y y y y
Visit Type (circle one):
Screening
Baseline
Visit 1
Visit 2
Visit 3
Visit 4
Visit 5
Completion Visit
CATEGORY
Normal
Or Abnormal
IF Abnormal, Describe below
Change from baseline
General Appearance
Normal
Abnormal
Not Examined
Yes
No
NA
HEENT
Normal
Abnormal
Not Examined
Yes
No
NA
Neck
Normal
Abnormal
Not Examined
Yes
No
NA
Chest and Lungs
Normal
Abnormal
Not Examined
Yes
No
NA
Cardiovascular
Normal
Abnormal
Not Examined
Yes
No
NA
Abdomen
Normal
Abnormal
Not Examined
Yes
No
NA
Genitourinary
Normal
Abnormal
Not Examined
Yes
No
NA
Rectal
Normal
Abnormal
Not Examined
Yes
No
NA
Musculoskeletal
Normal
Abnormal
Not Examined
Yes
No
NA
Lymph Nodes
Normal
Abnormal
Not Examined
Yes
No
NA
Extremities/Skin
Normal
Abnormal
Not Examined
Yes
No
NA
Neurological
Normal
Abnormal
Not Examined
Yes
No
NA
Other:__________
Normal
Abnormal
Not Examined
Yes
No
NA
Note: For follow-up PE, if a body system category changes from
“Normal” at baseline to “Abnormal” at follow-up due to a new
disease/condition, or a preexisting disease/condition worsens from the
baseline, an adverse event form should be completed to report the
change.
PHYSICIAN SIGNATURE: ___________________________ DATE SIGNED ___ ___ /
___ ___ ___ / 2 0 ___ ___
d d m m m y y y y
Physical Exam 2 of 2 Version 1.0