SF88
Medical Record - Report of Medical Examination
Standard Form 88 (SF 88), Medical Record - Report of Medical Examination, is a two-page medical record form, Rev. 10/1994. Its footer says it is prescribed by GSA/ICMR under FIRMR (41 CFR) 201-9.202-1. GSA hosts a copy in its forms library.
The form records a medical examination: who was examined and the purpose of the examination, a clinical evaluation of body systems marked normal or abnormal, a dental chart, test results, measurements such as height, weight, blood pressure, pulse, vision and hearing, a summary of defects and diagnoses, recommendations, and whether the examinee is qualified or not qualified. Physicians, a dentist or physician, and a reviewing officer or approving authority print their names and sign.
The PDF prints no instructions, privacy notice or filing address. You can fill it out free in your browser on this page and download the result without an account.
Name, identification number, grade and component or position, home address, emergency contact, date and place of birth, age, sex, race, agency and organization unit, years of military and civilian service, the examiner and the purpose of the examination.
Items A to CC, from head, face, neck and scalp to pelvic, each checked normal or abnormal, or NE if not evaluated, with notes describing every abnormality.
A dental chart of teeth 1 to 32 with symbols, then urinalysis, chest X-ray or PPD, syphilis serology, EKG, blood type and HR factor, and other tests.
Height, weight, hair and eye color, build, temperature, blood pressure, pulse, vision tests, hearing and audiometer, and psychological and psychomotor tests.
Notes and significant or interval history, summary of defects and diagnoses, recommendations, physical profile and category, whether the examinee is qualified or not qualified, and any disqualifying defects by item number.
Typed or printed names and signatures of the physicians, the dentist or physician, and the reviewing officer or approving authority.
Enter the date of exam and items 1 to 13, then the examining facility or examiner, the rating or specialty of the examiner and the purpose of the examination in items 14 to 16.
The form says to check each item in the appropriate column and enter NE if not evaluated, and to describe every abnormality in detail with the pertinent item number before each comment.
Place the dental symbols above or below the tooth numbers as shown in the examples. The form says copies of test results are preferred as attachments.
Complete items 20 to 41 on the second page, which repeats the name and identification and records the number of sheets attached.
List diagnoses with item numbers in item 43 and recommendations in item 44, check whether the examinee is qualified or not qualified in item 46, and list any disqualifying defects by item number in item 47.
The physicians, the dentist or physician, and the reviewing officer or approving authority type or print their names and sign in items 48 to 51.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The PDF gives no filing address and no instructions on where the completed form goes.
The footer reads Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1.
Notes continue in item 42, and the form says to use additional sheets if necessary. Page 2 records the number of sheets attached.
The footer prints NSN 7540-00-634-6038 and STANDARD FORM 88 (Rev. 10-94).
The form prints these roles. It gives no instructions on who uses it or when.
No tool matches that search.
The footer says the form is prescribed by GSA/ICMR under FIRMR (41 CFR) 201-9.202-1. GSA hosts a copy in its forms library.
The form has lines for the typed or printed names and signatures of physicians, a dentist or physician, and a reviewing officer or approving authority.
In the item 17 clinical evaluation, the form says to check each item in the appropriate column and enter NE if not evaluated.
The PDF prints no filing address or routing instructions.
Item 19 says copies of results are preferred as attachments, and page 2 records the number of sheets attached.
The footer prints STANDARD FORM 88 (Rev. 10-94), and GSA's page lists the current revision date as 10/1994.
