Psychiatric Physical Exam Form
Please complete all sections below for the psychiatric physical examination intake.
Patient Full Name
*
First Name
Last Name
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Provider
Blood Pressure (mmHg)
Heart Rate (bpm)
Respiratory Rate (breaths/min)
Temperature (°C or °F)
General Appearance
Please Select
Well-groomed
Disheveled
Appropriately dressed
Inappropriately dressed
Other
Neurological Findings
Please Select
Normal
Abnormal gait
Tremor
Involuntary movements
Other
Additional Comments or Findings
Submit Exam
Should be Empty: