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Annual Physical Examination Form

The Annual Physical Examination form is a crucial document designed to gather comprehensive health information before a medical appointment. This form helps ensure that all necessary details are collected, minimizing the need for follow-up visits. By providing accurate and complete information, patients can facilitate a thorough evaluation of their health status.

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Annual Physical Examination Sample

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

⇓ PDF File

Instructions on Utilizing Annual Physical Examination

Completing the Annual Physical Examination form is an important step in preparing for your medical appointment. It helps ensure that your healthcare provider has all the necessary information to provide you with the best care. Follow these steps carefully to fill out the form accurately.

Personal Information: Fill in your name, date of exam, address, Social Security Number (SSN), date of birth, and sex. If someone is accompanying you, provide their name.
Medical History: List any significant health conditions or diagnoses. Include a summary of your medical history and any chronic health problems, if available.
Current Medications: Write down all medications you are currently taking. Include the medication name, dose, frequency, diagnosis, prescribing physician, and date prescribed. Indicate if you take medications independently and note any allergies or contraindicated medications.
Immunizations: Record the dates and types of immunizations you have received, including Tetanus/Diphtheria, Hepatitis B, Influenza, and Pneumovax. Specify any other immunizations as well.
Tuberculosis (TB) Screening: Provide the date the TB test was given and read, along with the results. If applicable, include the date and results of any chest x-ray.
Other Medical Tests: List any additional medical or diagnostic tests you have undergone, such as GYN exams, mammograms, prostate exams, and lab tests. Include dates and results for each.
Hospitalizations/Surgical Procedures: Document any hospitalizations or surgeries, including the date and reason for each.
General Physical Examination: Fill in your blood pressure, pulse, respirations, temperature, height, and weight.
Evaluation of Systems: For each body system listed, indicate if the findings were normal and provide any comments or descriptions as necessary.
Vision and Hearing Screening: Note whether further evaluation is recommended for vision and hearing screenings.
Additional Comments: Review your medical history summary and note any changes in medications, recommendations for health maintenance, dietary instructions, or limitations on activities.
Physician Information: Finally, print the name of your physician, their signature, date, address, and phone number.

Once you have filled out the form, review it for completeness and accuracy. Bring the completed form to your appointment to ensure a smooth process. This will help your healthcare provider deliver the best care tailored to your needs.

Misconceptions

Understanding the Annual Physical Examination form can be challenging, and there are several misconceptions that people often have. Here are five common misunderstandings:

All information is optional. Many believe that they can skip sections of the form. However, completing all information is crucial to avoid return visits and ensure a thorough evaluation.
Only current medications need to be listed. Some individuals think they only need to include medications they are currently taking. In reality, it is important to provide a complete history, including past medications, to give the healthcare provider a full picture of the patient’s health.
The form is only for adults. There is a misconception that the Annual Physical Examination form is only applicable to adults. In fact, it is designed for individuals of all ages, and children also require annual evaluations.
Immunization records are not necessary. Some people assume that they do not need to include their immunization history. This is incorrect; providing accurate immunization records is essential for proper health assessment and recommendations.
Results from previous exams are not relevant. Many individuals think that past medical history does not need to be referenced. However, previous results can significantly influence current health assessments and treatment plans, making them vital for the physician's review.

Documents used along the form

The Annual Physical Examination form is a crucial document for ensuring comprehensive health assessments. Several other forms and documents are typically used in conjunction with this form to provide a complete medical overview. Below is a list of these documents, each serving a specific purpose in the healthcare process.

Medical History Form: This form collects detailed information about a patient's past medical history, including previous illnesses, surgeries, and family health history. It helps healthcare providers understand the patient's background and any potential health risks.
Medication List: This document details all current medications the patient is taking, including dosages and prescribing physicians. It is essential for preventing drug interactions and ensuring safe medication management.
Immunization Record: This record tracks the patient's vaccination history. It includes dates of administration and types of vaccines received, which is vital for public health and individual protection.
Consent for Treatment Form: This form grants permission for healthcare providers to deliver medical care. It is a legal requirement and ensures that patients are informed about the procedures they will undergo.
Lab Test Requisition: This document is used to order specific laboratory tests based on the physician's evaluation. It includes details about the tests needed and is crucial for accurate diagnosis and treatment.
Referral Form: When a patient needs to see a specialist, this form is used to facilitate the referral process. It includes pertinent medical information and reasons for the referral.
Patient Registration Form: This initial form gathers basic demographic information about the patient, including contact details and insurance information. It is necessary for establishing the patient’s profile in the healthcare system.
Hold Harmless Agreement: This essential document safeguards one party from liability for specific risks, ensuring that individuals acknowledge their responsibility for potential injuries or damages. To learn more about this form, visit nypdfforms.com/hold-harmless-agreement-form/.
Follow-Up Care Plan: After the physical examination, this document outlines the recommended follow-up actions, including additional tests, specialist visits, or lifestyle changes to improve health outcomes.
Emergency Contact Form: This form lists individuals to contact in case of a medical emergency. It ensures that healthcare providers can reach the appropriate people quickly if needed.

Utilizing these documents alongside the Annual Physical Examination form allows for a thorough and organized approach to patient care. Each document plays a vital role in facilitating effective communication and ensuring that healthcare providers have all necessary information to make informed decisions regarding patient health.