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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

Common mistakes

Completing the Annual Physical Examination form accurately is essential for ensuring a smooth medical appointment. However, many people make common mistakes that can lead to unnecessary delays or complications. Here are eight mistakes to watch out for.

First, failing to provide complete personal information is a frequent error. Many individuals skip filling in their full name, address, or date of birth. This information is crucial for identification and record-keeping. Double-checking these details before submitting the form can prevent a lot of hassle.

Another mistake is neglecting to list current medications. Some people forget to include over-the-counter drugs or supplements. It's important to provide a comprehensive list, including dosage and frequency. This information helps healthcare providers make informed decisions about your care.

Additionally, people often overlook allergies and sensitivities. Not mentioning these can lead to serious health risks during examinations or treatments. Make sure to detail any known allergies, including food, medication, and environmental factors.

In the immunizations section, many individuals fail to provide accurate dates or forget to mention previous vaccinations. Keeping a record of immunizations is essential for proper medical care. If unsure about your immunization history, consult your healthcare provider before filling out the form.

Another common error involves the evaluation of systems. Some individuals check "Yes" or "No" without providing comments or descriptions. This lack of detail can leave healthcare providers without crucial information about your health status. Clear communication in this section is vital for effective diagnosis and treatment.

People also frequently ignore the section about hospitalizations or surgical procedures. Omitting this information can result in incomplete medical histories. If you have undergone any procedures, list them with dates and reasons to ensure your healthcare provider has a full understanding of your medical background.

Moreover, failing to indicate whether a change in health status has occurred since the last examination is a mistake many make. This information can significantly impact your care plan. Be honest and thorough when answering this question.

Finally, some individuals forget to sign and date the form. This step is crucial for validating the information provided. Without a signature, the form may be considered incomplete, leading to delays in receiving care.

By being aware of these common mistakes and taking the time to fill out the Annual Physical Examination form carefully, individuals can ensure a more efficient and effective healthcare experience.

Dos and Don'ts

Completing the Annual Physical Examination form accurately is crucial for ensuring a smooth medical appointment. Here are some important dos and don'ts to keep in mind:

  • Do fill out all sections completely to avoid delays.
  • Do provide accurate personal information, including your name and date of birth.
  • Do list all current medications, including dosage and frequency.
  • Do mention any allergies or sensitivities clearly.
  • Do indicate if you have had any recent hospitalizations or surgeries.
  • Don't leave any required fields blank; incomplete forms may lead to return visits.
  • Don't forget to check the box for communicable diseases if applicable.
  • Don't omit details about your medical history or significant health conditions.
  • Don't hesitate to ask for help if you are unsure about how to fill out any section.

By following these guidelines, you can help ensure that your Annual Physical Examination form is completed correctly and efficiently.

Similar forms

The Annual Physical Examination form is an essential document for assessing an individual's health status. Several other documents share similarities with this form, as they all aim to collect important health information. Here’s a look at seven such documents:

  • Patient Intake Form: Like the Annual Physical Examination form, this document gathers personal details, medical history, and current medications from patients before their first visit to a healthcare provider.
  • Medical History Questionnaire: This form focuses on a patient's past health issues, surgeries, and family medical history, similar to the section on diagnoses and significant health conditions in the Annual Physical Examination form.
  • Medication Reconciliation Form: Both documents require patients to list their current medications, including dosages and prescribing physicians, ensuring that healthcare providers have accurate medication information.
  • Immunization Record: Just as the Annual Physical Examination form tracks immunizations, this record documents vaccinations a patient has received, helping to maintain an up-to-date health profile.
  • Referral Form: This document is used when a healthcare provider refers a patient to a specialist. It often includes pertinent medical history and current health concerns, mirroring the comprehensive evaluation found in the Annual Physical Examination form.
  • Hold Harmless Agreement: A TopTemplates.info provides a thorough template for a Hold Harmless Agreement, which is essential for shifting liability in various situations, ensuring parties are protected from potential risks associated with their activities.
  • Consent for Treatment Form: Similar to the Annual Physical Examination form, this document collects patient information and requires signatures, ensuring that patients understand and agree to the proposed medical evaluations and treatments.
  • Follow-Up Visit Form: After an initial examination, this form is used to track changes in a patient’s health status and any new medications or treatments, much like the recommendations and changes noted in the Annual Physical Examination form.

These documents, while serving different purposes, all contribute to a comprehensive understanding of a patient's health and ensure that healthcare providers can deliver the best possible care.