Pediatric Physical Examination Form
Patient Information
Full Name
Date of Birth
Sex
Male
Female
Parent/Guardian Name
Contact Number
Vital Signs
Height (cm)
Weight (kg)
Temperature (°C)
Heart Rate (bpm)
Respiratory Rate
Blood Pressure
General Appearance
Skin
Head, Eyes, Ears, Nose, Throat (HEENT)
Neck
Chest / Lungs
Cardiac
Abdomen
Genitalia
Extremities
Neurologic
Assessment / Plan
Examiner Name
Date of Exam