MEDICAL INFORMATION FORM.

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VITAL SIGN FORM

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VISUAL TESTING FORM

Snellen Corrected Uncorrected
OD
OS
OU
Projector Corrected Uncorrected
OD
OS
OU
Jaeger's Test Corrected Uncorrected
OD
OS
OU




Plates Patient Normal Person Person with Red-Green Deficiencies Person with total Color Blindness
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Protan
Strong Mild
Deutan
Strong Mild
16
6 (2)6 2 (2)6
17
6 (2)6 2 (2)6

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AUDIOMETRY FORM

AIR 500 1000 2000 3000 4000 6000
R.E
L.E
BONE
R.E
L.E
FF
7
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SPIROMETRY FORM

INDEX Meas. Normal Range Pred %Pred Z Score
FVC 3.00-472 L
FEV1 2.47-3.86 L
FEV1/FVC% 72.9-90.9%
PEF L/s
FEF25-75% 1.95-5.01 L/s
MEF25% 0.68-2.45 L/s
MEF50% L/s
MEF75% L/s
FEV6 L/s
FEV1/FEV6% %
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ECG FORM

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STRESS FORM

STAGE SPED(mph) GRADE OXYGEN CONSUMPTION (m102/kg/min) WORKLOADS (METS) In the Liquidated Society TOTAL TIME ELAPSED (min) BP HR RECOVERY
min BP HR
Supine 0
Standing 1
1 1.7 10 16.26 4.6 3 3
2 2.5 12 24.68 7 6 5
3 3.4 14 35.59 10.1 9 8
4 4.2 16 47.2 13.4 12 11
5 5 18 60.35 17.2 15 14
6 5.5 20 71.34 20.3 18 17
7 6 22 83.7 23.8 21 20
REASON FOR TERMINATION
HIGH RISK CATEGORY
CARDIO RESPIRATORY FITNESS
ECG
ABNORMAL RESPONSE
ANGINA SCORING SCALE
In the Liquidated Society
Normal Abnormal Stage
BP
HR
Time duration score: min sec
EXERCISE BP & HR: METS
EXERCISE BP & HR: METS
NORMAL STRESS TEST AT METS
NORMAL STRESS TEST AT METS
NORMAL STRESS TEST AT METS
NORMAL STRESS TEST AT METS
Cardiologist
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DENTAL FORM

To be accomplished by the attending Dentist

Past Dental History
Previous Extraction
Fainting
Diziness
Prolonged Bleeding Time
Allergy
Drugs
Oray Hygiene
Vitamins
For Diabetes
For Hypertension
Under Medication
Oray Hygiene
Calculus
Dental
Carries Activity
Abnormalities and Phatologic Findings
Clinical Examination of the Teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Legend

 - TOOTH PRESENT W/O CARIES, C - CARIES, AM - AMALGAM, CO - COMPOSITE, M - MISSING, TF - TEMPORARY FILLING, RF - ROOT FRAGMENT,
 X - FOR EXTRACTION, JC - JACKET CROWN, FB - FIXED BRIDGE, UN - UNERUPTED, IM - IMPACTED, RCT - ROOT CENAL TREATMENT,
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PYSCHO FORM

TEST ADMINISTERED

Intelligence Test(IQ) PNLT - A
Personality Test SSCT / DAPT
Others: Interview

I.INTELECTUAL LEVEL:
II.PERSONALITY TRAITS AND CHARACTERISTICS

1. RESTRAIN
Professions
Obedient
Self Disciplined
Enthusiastic
Venturesome
2. EMOTIONAL STABILITY
Can withstand isolation and boredom
Can withstand extreme noise, vibration and temperature
Faces reality
Confident
Tolerant to stress
Relaxed
3. OBJECTIVITY
Realistic
Free of Jealousy/Envy/Suspiciousness
Practical minded
Adaptability
4. MOTIVATION
Assertive
Indipendent
Resourceful
5. GOAL ORIENTATION
Direct one’s effort towards clear objectives
True False
1. It's easy for me to keep fit and healthy.
2. My present situation is hopeless.
3. I care about what other people think of me.
4. Sometimes I feel like smashing things.
5. I would enjoy betting on horses.
6. No one is making things work out badly for me.
7. I feel frightened when I have to go out alone.
8. I never have visions of imaginary people or things.
9. Many times I act without thinking.
10. I enjoy being with people.
11. I have given up hope of ever amounting to anything.
12. I frequently think of the same silly thing over and over for hours.
13. Sometimes my legs lose their strength so that I can't walk.
14. I rarely feel disappointed.
15. Very few things excite me.
16. I would never intentionally hurt someone's feelings.
17. For the most part people are honest.
18. Someone has stolen my free will.
19. Even at the end of a hard day, I remain relaxed and at ease.
20. I seem to hear an unknown voice wherever I go.
21. I would not do something foolhardy just for the fun of it.
22. I keep my distance from other people.
23. I deserve my share of good luck.
24. There have been days when I have done things without
being able to recall anything at all about them.
25. I am free of aches and pains.
True False
26. There is not much to be interested in any more.
27. Some movies make me quite happy or sad.
28. No one gets away with insulting me.
29. I have been in trouble with the law more than once.
30. Others rarely try to get the best of me.
31. Although I really try, I cannot stop feeling tense.
32. I do not hear peculiar voices warning me of danger.
33. I often behave in a reckless manner.
34. I like to speak to strangers.
35. I am only suited for the lowest and most simple sort of work.
36. I sometimes have fits and seizures that I cannot control.
37. My stomach is easily upset.
38. My future is cheery.
39. I would not be tempted by a promise of getting something for nothing.
40. I can get along quite well with irritable people.
41. No matter how easy or safe it was, I would never steal money.
42. I can tell that someone has searched through my possessions a number of times.
43. I remain quite cool when things go badly.
44. Fancy colored lights sometimes float through my brain.
45. Ideas do not race through my head faster than I can speak them.
46. Most of the time I prefer to be alone..
47. I am the type of person who can be relied upon.
48. My life is not worth living.
49. I seldom have any bodily discomfort.
50. I live a gloomy and boring life.
True False
51. At times I say things about my friends that aren't nice.
52. If someone does something I dislike, I usually tell that person about it.
53. I would enjoy cheating certain people..
54. No one is out to do away with me.
55. It frightens me to think about things that bother me.
56. Ordinary things never appear "foggy" or far away to me.
57.Sometimes I suddenly get up and act without warning or reason.
58. I would rather work with a group of people than by myself.
59. I am no good to anyone.
60. I have nightmares almost every night.
61. My skin is often red and inflamed.
62. I enjoy just about everything I do.
63. I never weep or feel like weeping.
64. I don't mind having someone tell rue what to do.
65. There is no excuse for taking advantage of someone of the opposite sex.
66. I feel that I am in great danger from those who wish to harm me.
67. Other people's actions rarely make me anxious.
68. I sometimes hear voices which no one else understands.
69. I am careful in almost everything I do.
70. I try not to get involved in conversations with others.
71. I think my parents would have reason to be proud of me./td>
72. I have strange fears of places and things.
73. My back does not bother me.
74. Others seem to lead happier lives than I do.
75. I can remember a few unpleasant things about my childhood.
True False
76. Slow people make me angry.
77. I think that I could commit a crime and get away with it.
78. People rarely look for my weaknesses.
79. I worry when a train or bus is late.
80. I never confuse my own thoughts with a real person talking to me.
81. I'll try almost anything regardless of the consequences.
82. I have a number of close friends.
83. My whole life is one big mistake.
84. I have periods when my mind races ahead so fast that I cannot think clearly.
85. Whenever I am worried about something I get cramps.
86. I live a very satisfying and rewarding life.
87. I am careful not to have any bad thoughts.
88. My family life has been happy and free of arguments.
89. Most salespeople would not cheat a customer.
90. When people whisper, I feel they might be talking about me.
91. I have the ability to concentrate without my mind wandering.
92. I see bright pictures in my head when I don't want to.
93. I can work fora reasonable length of time without becoming bored.
94. I avoid speaking with people as much as I can.
95. I usually do most of my daily tasks quite well.
96. Sometimes I feel as if I am about to lose my mind.
97. I seldom have a cough or sore throat.
98. Life is extremely dull for me.
99. I try to avoid jobs I dislike.
100. Bossy people can expect an argument from me.
True False
101. No one does something for nothing.
102. Most people treat me openly without hiding anything.
103 Sometimes my own thoughts scare me so much that I think I'm going to pass out.
104. My memory is as good as it ever was./td>
105. I often take risks without stopping to think about the results.
106. I dislike going out alone.
107. People are better off without me.
108. I frequently experience terrible headaches.
109. I often have pains in odd parts of my body.
110. Something interesting happens to me almost every day.
111. I am never cross with a loved one.
112. I avoid quarreling with others.
113. Gambling has no appeal to me.
114. I often have the feeling that I am not liked.
115. I generally feel quite comfortable when being introduced to strangers.
116. I sometimes find it difficult to tell whether a minute or an hour has passed.
117. I am not the type to be bored one minute and excited the next.
118. I am happier alone than when with others.
119. Most people find me an interesting person to talk with.
120. If things don't improve for me, I may have to do something violent or dangerous.
121. I hardly ever have "splitting" headaches.
122. I often have trouble sleeping because I feel so sad.
123. On some days I am more easily annoyed than on others.
124. I like to run my own life without interference from anyone.
125. I admire a successful professional thief.
True False
126. I never feel like a machine that someone else plugs in and uses.
127. When I am startled my heart seems to skip -a beat and stop.
128.Things don't appear strange to me right now.
129. I am usually somewhat restless.
130. I like talking to just about anyone I meet.
131. I am not worthy of other people's kindness.
132. There have been periods of time when I have used alcohol to excess.
133. Sometimes I get so dizzy I can hardly stand up.
134. I always look forward to a new day.
135. I have never lied to anyone.
136. I believe in obeying those in authority.
137. I was not regarded as a behavior problem by my school teachers.
138. I am greatly concerned with what people think about me.
139. Emergencies seldom make me nervous.
140. I often see shadows and think they are people or animals.
141. My feelings about people do not change much from day to day.
142.I don't care whether or not the people around me are my friends.
143. I enjoy the respect of most people who know me.
144. I have often used dangerous drugs or chemicals.
145. I generally feel warm enough.
1146. I don't think things will ever get any better for me.
147. Occasionally I use my friends to my own advantage
148. I dislike working for a person who is too strict.
149.Someone is always trying to trick you.
150. I am sure that no one gossips about me.
True False
151. Little things often upset me.
152.I usually know about what time it is.
153. I often leave jobs unfinished.
154. When I am not feeling well, I like to have someone around to comfort me.
155. I am not a particularly kind person.
156. I would enjoy watching someone suffer great pain.
157. I often have eye strain upon completing a day's work.
158. I believe that life is worth living.
159. I don't like thinking about personal problems.
160. I take great pains to be careful about other people's feelings.
161. There are many things I consider wrong and wouldn't do.
162. I often feel that others are trying to keep me out of their group.
163.I remain calm even in the most trying situations.
164. I often have the feeling that imaginary things are happening to me.
165. I generally make careful plans.
166. I am not considered sociable.
167. I think I would make a very good leader.
168. I do not care what happens to me.
169. My joints give me no trouble.
170. I feel depressed most of the time.
171. As a child I sometimes felt that my parents acted unfairly.
172. If someone hurts me, I remember it until I can get even.
173. People are always trying to get away with something.
174. No one has a magical power to control me.
175. I am sometimes disturbed by things that I know can't hurt me.
True False
176. Even when left alone, I can find my way around easily.
177. At times I am rather careless.
178. I enjoy being neighborly.
179. I often show poor judgment about things.
180. I sometimes have an urge to injure myself.
181. I have poor blood circulation.
182.I am quite content with life as it is now.
183. I admit my mistakes without ever trying to hide anything.
184. I seldom feel like hitting anyone.
185. I would feel very guilty if I were caught doing something wrong.
186. I never feel comfortable eating food prepared by others.
187. I don't worry about what might happen to me.
188. At times my surroundings change so much that I think I'm somewhere else.
189.I never take unnecessary chances.
190. I don't need other people.
191. I feel capable of handling many difficult jobs.
192. I have been in serious trouble with the law.
193. I have a good deal of energy.
194. I dislike doing anything new.
195. My feelings are sometimes hurt by loved ones.
196. I dislike being ordered around by anyone.
197. I would do just about anything for money.
198. If I fail at something I can only blame myself.
199. I am usually too afraid to try anything new.
200. I never see things that other people cannot see.
True False
201. I usually say the first thing that comes into my mind.
202. I truly enjoy myself at social events.
203. People dislike me because I have so many faults.
204. I spend a great deal of time day-dreaming about things that only I know.
205. I lose my breath easily.
206. I am usually a happy person.
207. I've never let down a friend in any way.
208. I do not easily lose patience with others.
209. Most people do what they can to help others.
210. I'm usually the first to be blamed if something goes wrong.
211. Things that upset other people usually do not bother me.
212. I cannot separate my daydreams from the real world.
213. I have a well thought out reason for almost everything I undertake.
214. I like to keep my ideas to myself.
215. I consider myself to be a generous and pleasant person.
216. I have been planning to do away with myself.
217. I never feel faint.
218. Recent events have made me feel downhearted and miserable.
219. Sometimes I deliberately avoid a person I dislike. .
220. I get very irritated when someone disagrees with me.
True False
221. I sometimes have fun teasing animals.
222. No one is trying to ruin my life..
223. When I visit a strange place, I become very upset.
224. I can easily understand simple directions.
225. I find it exciting to drive in a fast car.
226. I enjoy doing things with friends whenever I am able.
227. I am not the type of person one remembers after one meeting.
228. I do not care for anyone very much.
229. I get a lot of headaches.
230. I believe that I shall have my share of good luck.
True False
231. I always meet my responsibilities.
232. I am not hot-tempered.
233. Sooner or later people who break the-law get caught.
234. If certain individuals had not interfered, I would be more successful today.
235. I do not panic more quickly than the average person.
236. Many times I can hear mysterious voices all around me.
237. I seldom do silly things without thinking.
238. I make little effort to meet new people.
239. Much of what I say is worth paying attention to.
240. I always have difficulty in sleeping.
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TABULATED PSYCHOLOGICAL EVALUATION FORM

TEST ADMINISTERED

I. INTELLECTUAL LEVEL

II. PERSONALITY TRAITS AND CHARACTERISTERISTICS

Sense of Responsibility
Perserverance
Obedience
Self-disicipline/orderly
Enthusiasm
Initiative
Emotional Stability
Can withstand Boredom and work and and inconveniences
Face reality
Relaxed
Enthusiasm
Initiative
Objectivity
Tough-mindedness
Adaptability
Practically
Motivation
Assertiveness
Independence
Resourcefulness
Interpersonal and Personal Adjustment
Relationship with Peers and Co-workers (Team manship)
Relationship with Superior, Employers and authority Figures (Difference)
Self esteem
Aggressive Tendencies
Goal Orientation
Direct one’s effort towards clear cut objectives

III. CONCLUSION/REMARKS
()RECOMMENDED

No significant personality problems noted at the time of evaluation

()RECOMMENDED
LEGEND

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