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.
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:
Results:______________________________________________________
(digital method-males 40 and over)
Hemoccult
Urinalysis
Date:______________
Results: _________________________________________________
CBC/Differential
Results: ______________________________________________________
Hepatitis B Screening
PSA
Other (specify)___________________________________________Date:______________
Results: ________________________________
HOSPITALIZATIONS/SURGICAL PROCEDURES:
Date
Reason
12/11/09, revised 7/24/12
PART TWO: GENERAL PHYSICAL EXAMINATION
Blood Pressure:______ /_______ Pulse:_________
Respirations:_________ Temp:_________ Height:_________
Weight:_________
EVALUATION OF SYSTEMS
System Name
Normal Findings?
Comments/Description
Eyes
Ears
Nose
Mouth/Throat
Head/Face/Neck
Breasts
Lungs
Cardiovascular
Extremities
Abdomen
Gastrointestinal
Musculoskeletal
Integumentary
Renal/Urinary
Reproductive
Lymphatic
Endocrine
Nervous System
VISION SCREENING
Is further evaluation recommended by specialist?
HEARING SCREENING
ADDITIONAL COMMENTS:
Medical history summary reviewed?
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?
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
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
Physician Address: _____________________________________________
Physician Phone Number: ____________________________
Misconceptions about the Annual Physical Examination form can lead to confusion and missed opportunities for healthcare. Here are eight common misconceptions explained:
Completing the Annual Physical Examination form accurately is crucial for ensuring a smooth medical appointment. Here are some key takeaways to consider:
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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