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The Annual Physical Examination form is an essential tool for ensuring that patients receive comprehensive healthcare. This form captures vital information about an individual’s medical history, current medications, and any significant health conditions. Before the medical appointment, patients must fill out their personal details, including name, date of birth, and address. It also prompts them to disclose allergies, sensitivities, and contraindicated medications. Immunization records are crucial, as they help healthcare providers assess vaccination history. The form includes sections for tuberculosis screening and other medical tests, such as mammograms and prostate exams, which are vital for preventive care. During the physical examination, healthcare providers evaluate various systems, including cardiovascular and respiratory health, and record essential metrics like blood pressure and weight. Patients are encouraged to share any changes in health status, limitations, or special needs. By completing this form thoroughly, individuals can help ensure that their healthcare providers have the necessary information to offer the best possible care.

Annual Physical Examination Preview

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

  1. Incomplete Personal Information: Failing to fill out all sections, such as the name, date of exam, or address, can lead to delays in processing the form.

  2. Missing Medical History: Not including a summary of past medical conditions or significant health issues can hinder the physician's understanding of the patient's health.

  3. Omitting Current Medications: Forgetting to list all medications, including dosage and frequency, may result in dangerous drug interactions.

  4. Allergies Not Specified: Failing to disclose allergies or sensitivities can lead to adverse reactions during examinations or treatments.

  5. Ignoring Immunization Records: Not providing accurate dates for immunizations can complicate preventive care and health assessments.

  6. Inaccurate Health Screening Results: Reporting incorrect results for tests such as blood pressure or cholesterol can mislead the physician.

  7. Neglecting to Note Hospitalizations: Omitting recent hospital stays or surgeries can prevent the doctor from fully understanding the patient's medical history.

  8. Forgetting to Review Recommendations: Not checking off whether medical history was reviewed or if any special instructions were provided may lead to missed follow-up care.

Dos and Don'ts

When filling out the Annual Physical Examination form, here are six important things to do and avoid:

  • Do: Complete all sections of the form to ensure a smooth appointment.
  • Do: Provide accurate information regarding your medical history and current medications.
  • Do: List any allergies or sensitivities clearly to prevent any adverse reactions during treatment.
  • Do: Bring a list of any questions or concerns you may have for your healthcare provider.
  • Don't: Leave any sections blank; incomplete forms may require you to return for additional visits.
  • Don't: Forget to sign and date the form, as it is essential for processing your information.

Misconceptions

Here are some common misconceptions about the Annual Physical Examination form:

  • It's only for sick people. Many believe that the Annual Physical Examination is only necessary for those who are unwell. In reality, this exam is a preventive measure for everyone, helping to identify potential health issues before they become serious.
  • All information is optional. Some think that filling out the form is not mandatory. However, providing complete and accurate information is essential to ensure proper evaluation and care during the medical appointment.
  • Medications don’t need to be listed if they’re over-the-counter. Many people assume that only prescription medications need to be reported. However, it’s important to list all medications, including over-the-counter drugs, as they can affect health assessments and treatment plans.
  • Immunizations are not important to include. Some individuals may feel that their vaccination history is irrelevant. In fact, documenting immunizations helps healthcare providers understand your health status and ensure you receive necessary vaccinations.
  • The form is only relevant for adults. A misconception exists that only adults need to fill out this form. However, children and teenagers also benefit from annual physicals, and their health histories should be accurately documented.
  • Results are not necessary to report. Some may think that they don’t need to include results from previous tests or exams. On the contrary, providing this information allows healthcare providers to track changes in health over time.
  • It's a one-time requirement. Many believe that once they fill out the form, they don’t need to do it again. However, annual physical exams are typically required every year to monitor ongoing health and adjust care as needed.

Detailed Guide for Using Annual Physical Examination

Completing the Annual Physical Examination form is an important step in ensuring a thorough assessment of your health. After filling out the form, it will be submitted to your healthcare provider before your appointment. This allows the provider to review your medical history and current health status, facilitating a more effective examination.

  1. Personal Information: Fill in your name, date of the exam, address, Social Security Number (SSN), date of birth, and sex (check the appropriate box).
  2. Accompanying Person: If someone is accompanying you, write their name in the designated space.
  3. Health Conditions: List any significant health conditions or diagnoses, including a summary of your medical history and any chronic health problems.
  4. Current Medications: Document all medications you are currently taking. Include the medication name, dose, frequency, diagnosis, prescribing physician, and specialty. Indicate whether you take medications independently.
  5. Allergies/Sensitivities: Note any allergies or sensitivities you have.
  6. Immunizations: Record dates and types of immunizations received, including Tetanus/Diphtheria, Hepatitis B, Influenza, Pneumovax, and any others.
  7. Tuberculosis Screening: Provide the date the TB test was given and read, along with the results. If applicable, note the date and results of any chest x-ray.
  8. Communicable Diseases: Indicate whether you are free of communicable diseases and list any necessary precautions if you are not.
  9. Medical Tests: Document any other medical, lab, or diagnostic tests you have undergone, including dates and results.
  10. Hospitalizations/Surgical Procedures: List any hospitalizations or surgeries, including dates and reasons.
  11. General Physical Examination: Fill in your blood pressure, pulse, respirations, temperature, height, and weight.
  12. Evaluation of Systems: For each system listed, indicate whether findings were normal and provide comments if necessary.
  13. Vision and Hearing Screening: Indicate whether further evaluation is recommended for vision and hearing.
  14. Additional Comments: Include any additional comments regarding medical history, medications, health maintenance recommendations, and any limitations or restrictions on activities.
  15. Physician Information: Finally, have your physician print their name, sign, and date the form. Include the physician's address and phone number.