Physical Examination
Exam Date :
Student Name ________________________________________________________________ Address ______________________________________________________________________ City __________________________________________ State ________ Zip ________________ Age ______ Sex ______ Ht ______ Wt ______ T ______ P ______ R ______ B / P ______ Allergies ______________________________ Medications ____________________________
The above named individual has been examined by me and found to be free of any communicable diseases and physically able to participate in lifting , moving , and bathing patients in the Certified Nurses Aide Program .
Exam Comments / Notes :
Physician _____________________________________ Phone __________________________ Address ______________________________________________________________________ City __________________________________________ State ________ Zip ________________
Physicians Signature __________________________________________________________
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