The Annual Physical Examination Form is a crucial document designed to gather essential health information before your medical appointment. Completing this form helps ensure that your healthcare provider has a comprehensive understanding of your medical history and current health status. It’s important to fill it out accurately to avoid any unnecessary follow-up visits.
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The Annual Physical Examination form is a crucial document that helps ensure comprehensive health assessments for individuals. This form requires patients to provide essential information prior to their medical appointments, including personal details such as name, date of birth, and social security number. It also prompts individuals to disclose any significant health conditions, current medications, and allergies, which are vital for tailoring medical care. Immunization history is another key aspect, detailing vaccinations received and their dates, while tuberculosis screening results help monitor communicable diseases. The form also includes sections for various medical and diagnostic tests, such as GYN exams for women and prostate exams for men, which are important for preventive health measures. Additionally, the general physical examination section assesses vital signs and evaluates multiple body systems, allowing healthcare providers to identify any abnormalities. Recommendations for health maintenance and any necessary follow-up actions are also documented, ensuring that patients receive appropriate care and guidance. Overall, the Annual Physical Examination form serves as a comprehensive tool for both patients and healthcare providers, facilitating effective communication and promoting proactive health management.
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: ____________________________
High School Transcript - Typically issued by the high school or educational institution attended.
Free Printable Shared Well Agreement - Emergency repairs can be carried out without prior consent in the event of system failures.
A California Non-disclosure Agreement (NDA) is a legal document designed to protect confidential information shared between parties. By establishing clear boundaries around sensitive data, this form helps prevent unauthorized disclosure and misuse. If you need to safeguard your proprietary information, consider filling out the NDA form by visiting califroniatemplates.com for more details.
Parental Consent Form - Parents use this form to indicate their agreement for the school to utilize student data.
Misconceptions about the Annual Physical Examination form can lead to confusion and incomplete submissions. Here are four common misconceptions:
The Annual Physical Examination form is an important document used to gather comprehensive health information about an individual. Alongside this form, several other documents may be required to ensure a complete assessment of the patient's health. Below is a list of common forms and documents that are often used in conjunction with the Annual Physical Examination form.
Having these documents prepared and completed can streamline the process of the Annual Physical Examination. They help healthcare providers deliver thorough and personalized care, ensuring that all aspects of the patient's health are considered.