The Annual Physical Examination form is a comprehensive document designed to gather essential health information prior to a medical appointment. It captures vital details such as medical history, current medications, and any significant health conditions. Completing this form accurately helps ensure a thorough evaluation during the physical examination, ultimately promoting better health outcomes.
The Annual Physical Examination form is a crucial tool that helps ensure individuals receive comprehensive health assessments. It is designed to gather essential information before a medical appointment, including personal details such as name, date of birth, and contact information. The form also requests a summary of medical history, current medications, and any known allergies. This section is vital for healthcare providers to understand existing health conditions and medication interactions. Immunization records are also included, outlining vaccinations like Tetanus, Hepatitis B, and Influenza, which are important for preventive care. Additionally, the form addresses tuberculosis screening, various diagnostic tests, and any past hospitalizations or surgeries. The second part of the form focuses on the general physical examination, documenting vital signs and evaluations of different body systems. This includes assessments of the eyes, ears, cardiovascular health, and more, ensuring a thorough overview of the patient's health status. By completing this form accurately, patients can help streamline their medical visits and enhance the quality of care they receive.
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Misconceptions about the Annual Physical Examination form can lead to confusion and incomplete submissions. Here are eight common misunderstandings explained:
Understanding these misconceptions can help ensure that you are prepared for your annual physical examination and receive the best possible care.
When filling out the Annual Physical Examination form, it is essential to provide accurate and complete information. Here are key takeaways to consider:
When filling out the Annual Physical Examination form, it's important to be thorough and accurate. Here are ten things to keep in mind:
By following these guidelines, you can help ensure a smooth process during your annual physical examination.
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: ____________________________