Blank Annual Physical Examination PDF Form Edit Document

Blank Annual Physical Examination PDF Form

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.

Sample - Annual Physical Examination Form

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

Document Breakdown

Fact Name Description
Purpose The Annual Physical Examination Form is designed to gather comprehensive health information before a medical appointment.
Required Information Patients must complete all sections of the form to prevent the need for return visits.
Medical History Patients should provide a summary of their medical history and any chronic health problems.
Current Medications A detailed list of current medications, including dosage and prescribing physician, is required.
Immunizations Immunization history must be documented, including dates for vaccines like Tetanus and Hepatitis B.
Screening Tests Various screenings, such as TB tests and GYN exams, are recommended based on age and gender.
Hospitalizations Patients are asked to list any hospitalizations or surgical procedures, including dates and reasons.
Evaluation of Systems The form includes a section for evaluating different body systems, indicating normal findings or concerns.
Legal Compliance In some states, the use of this form may be governed by specific health regulations, such as HIPAA for patient privacy.

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Misconceptions

Misconceptions about the Annual Physical Examination form can lead to confusion and incomplete submissions. Here are four common misconceptions:

  • All sections must be completed to avoid delays. Many believe that only certain sections are necessary. However, every part of the form is important for a comprehensive evaluation. Incomplete forms can lead to return visits and delays in care.
  • Immunizations are optional. Some individuals think that providing immunization history is not mandatory. In reality, this information is crucial for assessing overall health and ensuring that vaccinations are up to date.
  • Past medical history is irrelevant. A common belief is that only current health conditions matter. However, understanding a patient’s medical history, including past surgeries and hospitalizations, is vital for accurate diagnosis and treatment.
  • Medications do not need to be listed if they are not currently taken. Some people assume they can skip listing medications they no longer use. This is misleading; all past medications should be documented. This helps healthcare providers understand potential drug interactions and the patient’s treatment history.

Documents used along the form

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.

  • Medical History Form: This document collects detailed information about a patient's past medical conditions, surgeries, and family health history. It helps healthcare providers understand the patient's background.
  • Medication List: A list of all current medications, including dosages and frequency, allows healthcare providers to assess potential drug interactions and ensure safe prescribing practices.
  • Immunization Record: This record shows all vaccinations received by the patient. It is essential for tracking immunization status and determining any necessary updates.
  • Consent for Treatment Form: This form provides permission for healthcare providers to deliver medical care. It ensures that patients understand and agree to the procedures and treatments they will receive.
  • Lab Test Requisition: This document requests specific laboratory tests to be performed. It includes details about the tests needed and helps in diagnosing health conditions.
  • Referral Form: If a specialist is needed, this form facilitates the referral process. It includes relevant patient information and the reason for the referral.
  • Insurance Information Form: This form collects details about the patient's insurance coverage. It is necessary for billing and ensuring that services are covered.
  • Patient Registration Form: This document gathers basic information about the patient, such as contact details and emergency contacts. It is often required for new patients.
  • Motor Vehicle Bill of Sale: For individuals involved in the purchase or sale of a vehicle, it's important to have a properly filled out Motor Vehicle Bill of Sale form. This document not only serves as proof of transaction but also aids in the registration process. For more information, visit txtemplate.com/motor-vehicle-bill-of-sale-pdf-template.
  • Release of Information Form: This form allows healthcare providers to share the patient's medical information with other entities, such as specialists or insurance companies, when necessary.
  • Advance Directive: This document outlines a patient's preferences for medical treatment in case they are unable to communicate their wishes in the future. It is crucial for ensuring that a patient's healthcare choices are respected.

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.