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Fill Out Your Annual Physical Examination Form

The Annual Physical Examination Form serves as a comprehensive tool for gathering essential health information prior to a medical appointment. This form collects personal details, medical history, current medications, and relevant health screenings to ensure a thorough evaluation. By completing this form accurately, individuals can help facilitate a more effective and efficient healthcare experience.

Form Sample

ANNUAL PHYSICAL EXAMINATION FORM

Please complete all information to avoid return visits.

PART ONE: TO BE COMPLETED PRIOR TO MEDICAL APPOINTMENT

Name: ___________________________________________

Date of Exam:_______________________

Address:__________________________________________

SSN:______________________________

_____________________________________________

Date of Birth: ________________________

Sex:

Male

Female

Name of Accompanying Person: __________________________

DIAGNOSES/SIGNIFICANT HEALTH CONDITIONS: (Include a Medical History Summary and Chronic Health Problems List, if available)

CURRENT MEDICATIONS: (Attach a second page if needed)

Medication Name

Dose

Frequency

Diagnosis

Prescribing Physician

Date Medication

 

 

 

 

Specialty

Prescribed

Does the person take medications independently?

Yes

No

Allergies/Sensitivities:_______________________________________________________________________________

Contraindicated Medication: _________________________________________________________________________

IMMUNIZATIONS:

Tetanus/Diphtheria (every 10 years):______/_____/______

Type administered: _________________________

Hepatitis B: #1 ____/_____/____

#2 _____/____/________

#3 _____/_____/______

Influenza (Flu):_____/_____/_____

 

 

Pneumovax: _____/_____/_____

 

 

Other: (specify)__________________________________________

 

TUBERCULOSIS (TB) SCREENING: (every 2 years by Mantoux method; if positive initial chest x-ray should be done)

Date given __________

Date read___________

Results_____________________________________

Chest x-ray (date)_____________

Results________________________________________________________

Is the person free of communicable diseases? Yes No (If no, list specific precautions to prevent the spread of disease to others)

_________________________________________________________________________________________________________

OTHER MEDICAL/LAB/DIAGNOSTIC TESTS:

GYN exam w/PAP:

Date_____________

Results_________________________________________________

(women over age 18)

 

 

Mammogram:

Date: _____________

Results: ________________________________________________

(every 2 years- women ages 40-49, yearly for women 50 and over)

Prostate Exam:

Date: _____________

Results:______________________________________________________

(digital method-males 40 and over)

 

 

 

Hemoccult

Date: _____________

Results:______________________________________________________

Urinalysis

Date:______________

Results: _________________________________________________

CBC/Differential

Date:______________

Results: ______________________________________________________

Hepatitis B Screening

Date:______________

Results: ______________________________________________________

PSA

Date:______________

Results: ______________________________________________________

Other (specify)___________________________________________Date:______________

Results: ________________________________

Other (specify)___________________________________________Date:______________

Results: ________________________________

HOSPITALIZATIONS/SURGICAL PROCEDURES:

Date

Reason

Date

Reason

12/11/09, revised 7/24/12

PART TWO: GENERAL PHYSICAL EXAMINATION

 

 

 

 

 

Please complete all information to avoid return visits.

 

 

 

 

Blood Pressure:______ /_______ Pulse:_________

Respirations:_________ Temp:_________ Height:_________

Weight:_________

 

 

EVALUATION OF SYSTEMS

 

 

 

 

 

 

 

 

 

 

 

 

 

System Name

 

Normal Findings?

Comments/Description

 

 

 

Eyes

 

Yes

No

 

 

 

 

 

Ears

 

Yes

No

 

 

 

 

 

Nose

 

Yes

No

 

 

 

 

 

Mouth/Throat

 

Yes

No

 

 

 

 

 

Head/Face/Neck

 

Yes

No

 

 

 

 

 

Breasts

 

Yes

No

 

 

 

 

 

Lungs

 

Yes

No

 

 

 

 

 

Cardiovascular

 

Yes

No

 

 

 

 

 

Extremities

 

Yes

No

 

 

 

 

 

Abdomen

 

Yes

No

 

 

 

 

 

Gastrointestinal

 

Yes

No

 

 

 

 

 

Musculoskeletal

 

Yes

No

 

 

 

 

 

Integumentary

 

Yes

No

 

 

 

 

 

Renal/Urinary

 

Yes

No

 

 

 

 

 

Reproductive

 

Yes

No

 

 

 

 

 

Lymphatic

 

Yes

No

 

 

 

 

 

Endocrine

 

Yes

No

 

 

 

 

 

Nervous System

 

Yes

No

 

 

 

 

 

VISION SCREENING

 

Yes

No

Is further evaluation recommended by specialist?

Yes

No

 

 

HEARING SCREENING

 

Yes

No

Is further evaluation recommended by specialist?

Yes

No

 

 

ADDITIONAL COMMENTS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical history summary reviewed?

Yes

No

 

 

Medication added, changed, or deleted: (from this appointment)__________________________________________________________

Special medication considerations or side effects: ________________________________________________________________

Recommendations for health maintenance: (include need for lab work at regular intervals, treatments, therapies, exercise, hygiene, weight control, etc.)

___________________________________________________________________________________________________________

Recommendations for manual breast exam or manual testicular exam: (include who will perform and frequency)____________________

___________________________________________________________________________________________________________

Recommended diet and special instructions: ____________________________________________________________________

Information pertinent to diagnosis and treatment in case of emergency:

___________________________________________________________________________________________________________

Limitations or restrictions for activities (including work day, lifting, standing, and bending): No Yes (specify)

___________________________________________________________________________________________________________

Does this person use adaptive equipment?

No

Yes (specify):________________________________________________

Change in health status from previous year? No

Yes (specify):_________________________________________________

This individual is recommended for ICF/ID level of care? (see attached explanation) Yes

No

Specialty consults recommended? No

Yes (specify):_________________________________________________________

Seizure Disorder present? No Yes (specify type):__________________________________ Date of Last Seizure: ______________

________________________________

_______________________________

_________________

Name of Physician (please print)

Physician’s Signature

 

Date

Physician Address: _____________________________________________

Physician Phone Number: ____________________________

12/11/09, revised 7/24/12

Misconceptions

Misconceptions about the Annual Physical Examination form can lead to confusion and missed opportunities for healthcare. Here are eight common misconceptions explained:

  • It's only for sick people. Many believe that an annual physical is only necessary if one is feeling unwell. In reality, these exams are essential for preventive care and overall health maintenance.
  • All information is optional. Some individuals think they can skip sections of the form. However, completing all information is crucial to avoid return visits and ensure accurate assessments.
  • Only doctors need to see the form. There is a misconception that only physicians review the form. In fact, nurses and other healthcare professionals also rely on this information for comprehensive care.
  • Medications don’t need to be listed if they are over-the-counter. People often overlook the importance of listing all medications, including over-the-counter drugs. This information is vital for avoiding drug interactions and ensuring safe treatment.
  • Immunizations are not necessary if you feel healthy. Some believe that if they feel fine, they don’t need to update immunizations. This is misleading; vaccinations are crucial for preventing serious diseases.
  • Results of tests are not important to document. There is a belief that results from previous tests do not need to be included. However, documenting these results helps in tracking health changes over time.
  • Only specific age groups need physical exams. Many think that only older adults require annual physicals. In truth, everyone, regardless of age, can benefit from regular check-ups.
  • Completing the form is a waste of time. Some individuals view filling out the form as unnecessary. Yet, providing accurate information can lead to better health outcomes and tailored medical advice.

Key takeaways

Completing the Annual Physical Examination form accurately is crucial for ensuring a smooth medical appointment. Here are some key takeaways to consider:

  • Complete All Sections: Fill in every section of the form to prevent delays or the need for return visits.
  • Provide Accurate Medical History: Include a summary of past diagnoses and any chronic health issues to help your healthcare provider understand your health better.
  • List Current Medications: Clearly document all medications you are currently taking, including dosages and prescribing physicians. This information is essential for safe medical care.
  • Note Allergies: Disclose any known allergies or sensitivities to medications or other substances to avoid potential complications during treatment.
  • Update Immunization Records: Ensure your immunizations are current, particularly for Tetanus, Hepatitis B, and Influenza. Include dates and types administered.
  • Communicable Diseases: Indicate whether you are free from communicable diseases. If not, provide specific precautions to prevent spreading illness.
  • Document Recent Tests: Record any recent medical tests or screenings, such as mammograms or prostate exams, along with their results.
  • Be Honest About Health Changes: If there have been any changes in your health status since the last examination, be sure to specify them on the form.
  • Consultation Recommendations: Note any recommendations for specialist consultations or additional evaluations that may be necessary based on your health status.

By adhering to these guidelines, individuals can enhance the effectiveness of their annual physical examination and ensure they receive the best possible care.

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