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Get Southern Illinois University Edwardsville Health Service Physical Examination

_____________________             ___________  Last Name  First Name  Middle Initial  ______________________________  ID Number  ___________________________  SSN  _________________________  Date of Birth (MO/DAY/YR)  Normal  Abnormal  Comments  Skin  Ears  Eyes  Nose  Throat  Mouth / Dental  Cardiovascular  Respiratory  Gastrointestinal  Genito­Urinary  Neurological  Musculoskeletal  Spinal examination  Nutritional status  Other  Height _.

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