| Question | Response |
|---|---|
| Date of Collection | |
| Was Physical Examination Performed? | Yes No |
| Appearance/Skin | Normal Abnormal Not Done |
| Appearance/Skin, Abnormal Specify | |
| Head/Neck (including Thyroid) | Normal Abnormal Not Done |
| Head/Neck (including Thyroid), Abnormal Specify | |
| Eyes-Ears-Nose_Throat | Normal Abnormal Not Done |
| Eyes-Ears-Nose_Throat, Abnormal Specify | |
| Cardiovascular | Normal Abnormal Not Done |
| Cardiovascular, Abnormal Specify | |
| Pulmonary | Normal Abnormal Not Done |
| Pulmonary, Abnormal Specify | |
| Abdomen | Normal Abnormal Not Done |
| Abdomen, Abnormal Specify | |
| Neurological | Normal Abnormal Not Done |
| Neurological, Abnormal Specify | |
| Musculoskeletal | Normal Abnormal Not Done |
| Musculoskeletal, Abnormal Specify | |
| Other | Normal Abnormal Not Done |
| Other, Abnormal Specify |