Pre-Placement Physical Exam

Patient Name:
DOB:
  /   /      (dd)/(mm)/(yyyy)
Email
Address:
City - Zip code
Resting Heart Rate:
Blood Pressure:
Normal Elevated
Highest Reading:
/
Height:
ft in.
Weight:
lb.

Physical Readings

General Appearance:
Normal
Abnormal
HEENT:
Normal
Abnormal
Lymph Nodes:
Normal
Abnormal
Chest:
Normal
Abnormal
Breast:
Normal
Abnormal
Lungs:
Normal
Abnormal
Heart:
Normal
Abnormal
Abdomen:
Normal
Abnormal
Genitalia:
Normal
Abnormal
Testes:
Normal
Abnormal
Spine:
Normal
Abnormal
Extremities:
Normal
Abnormal
Neurological:
Normal
Abnormal
Skin:
Normal
Abnormal
Prostate:
Normal
Abnormal
Notes


Exam Results:
Normal
Abnormal
Date
  /   /      (dd)/(mm)/(yyyy)
Examiner’s Signature:
Examiner’s Printed Name:
Examiner’s Address:
Examiner’s Phone:

NOTICE

Ojas Med Spa / Rejuvenation Center and other health organizations are required to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

MY RIGHTS

• I understand this authorization is voluntary. Treatment may not be conditioned on signing this authorization except if the authorization is for 1) conducting research related treatment, 2) creating health information to provide to a 3rd party.
• I may revoke this authorization at any time, provided I do so in writing and submit to Ojas Med Spa. The revocation will take effect when Ojas receives it.

• I have read and accepted the Ojas Med Spa / Rejuvenation Center. Privacy Policy Agreement
• I have read and accepted the Patient Authorization for Medical Care/Treatment Agreement