Date of Exam: (month/day/year) Was a physical exam performed on the participant/subject? Yes (Specify results below) No Table 1: Data collection grid Describe Abnormality or Comment if Body If Abnormality, Body System Result System is Not Clinically Significant? Examined Allergic/Immunologic Normal Data to be filled in by Clinically significant site Abnormal Not clinically significant Not examined Cardiovascular Normal Data to be filled in by Clinically significant site Abnormal Not clinically significant Not examined Constitutional Normal Data to be filled in by Clinically significant symptoms (e.g., fever, site Abnormal Not clinically significant weight loss) Not examined Ears, Nose, Mouth, and Normal Data to be filled in by Clinically significant Throat site Abnormal Not clinically significant Not examined Endocrine Data to be filled in by Normal Clinically significant site Abnormal Not clinically significant Not examined Eyes Normal Data to be filled in by Clinically significant site Abnormal Not clinically significant Not examined Gastrointestinal Normal Data to be filled in by Clinically significant site Abnormal Not clinically significant Not examined Genitourinary Normal Data to be filled in by Clinically significant site Abnormal Not clinically significant Not examined
Date of Exam: (month/day/year) Was a physical exam performed on the participant/subject? Yes (Specify results below) No Table 1: Data collection grid Body System Result Describe Abnormality or Comment if Body System is Not Examined If Abnormality, Clinically Significant? Allergic/Immunologic Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Cardiovascular Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Constitutional symptoms (e.g., fever, weight loss) Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Ears, Nose, Mouth, and Throat Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Endocrine Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Eyes Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Gastrointestinal Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Genitourinary Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant