Candidate Number

Examiner Name

Date

Time

Brief description of the case

RATE THE CANDIDATE IN THE FOLLOWING AREAS - Physical Examination
Unsatisfactory	Borderline	Satisfactory
Identifying Physical Signs
Unsatisfactory	Borderline	Satisfactory
Differential Diagnosis
Unsatisfactory	Borderline	Satisfactory
Clinical Judgement
Unsatisfactory	Borderline	Satisfactory
Maintaining Patient Welfare
Unsatisfactory	Borderline	Satisfactory

Overall score (1-Unsatisfactory, 2-Borderline, 3-Satisfactory)

1 3

1

Examiner Notes