Fill Out a Valid Annual Physical Examination Template Launch Editor Here

Fill Out a Valid Annual Physical Examination Template

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.

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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

Misconceptions about the Annual Physical Examination form can lead to confusion and incomplete submissions. Here are eight common misunderstandings explained:

  • It’s only for sick people. Many believe that an annual physical is only necessary if they are feeling unwell. In reality, regular check-ups help maintain overall health and prevent potential issues.
  • All information is optional. Some think that they can skip sections of the form. However, completing all requested information is crucial to ensure a thorough examination and avoid return visits.
  • Medications don’t need to be listed if they’re over-the-counter. This is incorrect. All medications, including over-the-counter drugs and supplements, should be reported to provide a complete picture of health.
  • Immunizations are only for children. Adults also need to stay updated on vaccinations. The form includes sections for adult immunizations, which are essential for ongoing health protection.
  • Only specific tests are required. While certain tests are standard, the form allows for additional tests based on individual health needs. It’s important to discuss any personal health concerns with the physician.
  • All findings will be normal. Some individuals assume that if they feel fine, all examination results will be normal. It’s essential to understand that some conditions may not present symptoms initially.
  • Once completed, the form doesn’t need to be updated. This is a misconception. Changes in health status, medications, or allergies should be updated annually to ensure accurate care.
  • Only the doctor reviews the form. In reality, the entire medical team may reference the information provided. Accurate and complete data helps everyone involved in your care.

Understanding these misconceptions can help ensure that you are prepared for your annual physical examination and receive the best possible care.

Key takeaways

When filling out the Annual Physical Examination form, it is essential to provide accurate and complete information. Here are key takeaways to consider:

  • Complete All Sections: Ensure that every section of the form is filled out completely to avoid any need for return visits.
  • Medical History: Include a summary of medical history and any chronic health problems. This information is vital for accurate assessment.
  • Current Medications: List all medications, including dosage and frequency. If necessary, attach an additional page for more details.
  • Immunization Records: Provide up-to-date immunization information. This includes dates and types of vaccinations received.
  • Screening Tests: Document any recent screenings, such as mammograms or prostate exams, along with their results.
  • Communication with Healthcare Provider: Ensure that any changes in health status or new medications are communicated to the physician during the visit.
  • Follow-Up Recommendations: Pay attention to any recommendations for follow-up tests or lifestyle changes provided by the physician after the examination.

Dos and Don'ts

When filling out the Annual Physical Examination form, it's important to be thorough and accurate. Here are ten things to keep in mind:

  • Do provide complete and accurate personal information, including your name, address, and date of birth.
  • Don't leave any sections blank. Incomplete forms may lead to delays or additional visits.
  • Do list all current medications, including dosage and frequency. Attach a second page if necessary.
  • Don't forget to mention any allergies or sensitivities. This information is crucial for your safety.
  • Do include any significant health conditions or medical history that may affect your care.
  • Don't assume that the healthcare provider will know your medical history. Always provide details.
  • Do answer all questions about immunizations and screenings honestly.
  • Don't ignore the importance of listing any hospitalizations or surgical procedures.
  • Do review the form for accuracy before submitting it. Double-check all entries.
  • Don't hesitate to ask for help if you're unsure about how to fill out any part of the form.

By following these guidelines, you can help ensure a smooth process during your annual physical examination.

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