The Annual Physical Examination Form is a crucial document used to gather essential health information before a medical appointment. This form ensures that all relevant details about your medical history, medications, and current health status are documented accurately. Completing it thoroughly helps streamline the examination process and enhances the quality of care you receive.
Patient Intake Form: Similar to the Annual Physical Examination form, the Patient Intake Form collects essential personal information, medical history, and current medications. Both documents aim to ensure that healthcare providers have a comprehensive understanding of the patient’s health status before an appointment.
Medical History Questionnaire: Like the Annual Physical Examination form, the Medical History Questionnaire gathers detailed information about past illnesses, surgeries, and family health history. This information helps healthcare providers assess risk factors and tailor treatment plans accordingly.
Consent for Treatment Form: This document, while focused on obtaining patient consent for specific medical procedures, shares similarities with the Annual Physical Examination form in that both require patient acknowledgment of their health conditions and treatments. Clarity in understanding is crucial for informed consent.
Immunization Record: The Immunization Record tracks vaccinations and is comparable to the Annual Physical Examination form, which includes a section on immunizations. Both documents ensure that healthcare providers are aware of the patient's vaccination history, which is essential for preventive care.
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: ____________________________
When filling out the Annual Physical Examination form, there are several important points to keep in mind to ensure a smooth process.
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Completing the Annual Physical Examination form is essential for ensuring that all necessary health information is accurately recorded before your medical appointment. This helps streamline the process and reduces the need for follow-up visits. Follow these steps carefully to fill out the form correctly.