Base Line Health Assessment For Printed
Base Line Health Assessment For Printed
Base Line Health Assessment For Printed
Address
Phone and Fax
IDENTITY
1
2
3
4
5
6
7
8
Name
Date of Birth
Place of Birth/ Nationality
Sex
Status
Occupation
Register Number
Address
:
:
:
: male/ female
: single/ family, children:
:
:
:
PHOTOGRAPH
ICD Code
None
Minor symptoms/ non significant condition
Contagious Disease
Physical Impairment or Disability
Mental Disorder
Addiction (abuse) of specific substances
Chronic Disease: DM, Hypertension etc
Pregnant
Other significant condition
Treatment
1
2
3
4
5
By Whom
by GP
by specialist, specify:
2.
Date:
schedule
1.
MEDICAL HISTORY
No Have you ever had or needed:
No
1 Illness or Injury requiring hospitalization or surgical intervention?
Yes
Date
PHYSICAL EXAMINATION
Was a chaperone present during the examination? (name and relationship)
Was an interpreter present during the examination? (name and relationship)
1 Date of Examination
2 BMI (weight-KG/ height-M2)
Weight (KG)
Height (cm)
Waist circumference (cm, >=20 years old
age)
Head Circumference (cm, <18 months old
3 age)
Left Mid Arm Circumference (abnormal
BMI, cm)
4 Visual Acuity
Uncorrected
Corrected
Pin Hole
Ishihara Test
Blood Pressure ( >=11 years old age, initial,
5 repeated, mmHg)
Pulse Rate and Rhytm
yes/ no
yes/ no
please specify if abnormal
right
left
Yes/ No
Date: