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HEALTH SCREENING RESULTS

Date
Month
Day
Year

Patient Details

Birthday
Month
Day
Year

Body

Vision Test

Snellen Test

Near

Left

Near

Right

Near

Both

Distance

Left

Distance

Right

Distance

Both

Visual Fields
Keystone Vision Test

Peak Expiratory Flow (PEF)

Urinalysis

Otoscopic Examination

Is there wax in the internal meatus?

Left Ear
Right Ear

Any abnormality of the external meatus?

Left Ear
Right Ear

Drum

Left Ear
Right ear

Tympanic Membrane

Left Ear
Right Ear

Audiometry Results

Frequency


Sum of hearing at:

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