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The Annual Physical Examination form serves as a vital tool in maintaining and assessing an individual’s health. This comprehensive document is designed to gather essential information prior to a medical appointment, ensuring that healthcare providers have a complete picture of the patient's medical history. It includes sections for personal details such as name, date of birth, and address, as well as critical health information like current medications, allergies, and significant health conditions. Immunization records are also a key component, detailing vaccinations like Tetanus, Hepatitis B, and Influenza. The form further addresses tuberculosis screening and outlines any necessary medical tests, such as GYN exams, mammograms, and prostate exams. Additionally, the general physical examination section captures vital signs and evaluates various bodily systems, allowing for a thorough assessment of the patient's overall health. By completing this form accurately, individuals can help streamline their healthcare experience, reduce the likelihood of return visits, and promote proactive health management.
Document Data
| Fact Name | Description |
|---|---|
| Purpose | The Annual Physical Examination form is designed to gather comprehensive health information from patients prior to their medical appointments. |
| Patient Information | Patients must provide personal details such as name, date of birth, and address to ensure proper identification and follow-up. |
| Medical History | Patients are encouraged to include a summary of their medical history and any chronic health problems. |
| Current Medications | The form requires patients to list all current medications, including dosage and prescribing physician. |
| Immunizations | Information about immunizations, including dates and types, must be documented to ensure up-to-date vaccinations. |
| TB Screening | Patients should report on tuberculosis screening, including the date given and results, as per health guidelines. |
| General Physical Examination | A section is included for vital signs and evaluations of various body systems, ensuring a thorough health assessment. |
| Special Recommendations | Patients receive recommendations for health maintenance, including dietary advice and exercise, based on their examination. |
| Limitations | The form allows for documentation of any activity limitations or restrictions that may affect the patient's daily life. |
| Physician Verification | The form must be signed by the physician, confirming that the examination and recommendations have been reviewed. |
How to Write Annual Physical Examination
Completing the Annual Physical Examination form is an important step in ensuring your health needs are addressed. After filling out the form, it will be reviewed by your healthcare provider during your appointment. This helps them understand your medical history, current medications, and any health concerns you may have.
- Begin with Part One of the form. Write your Name in the designated space.
- Fill in the Date of Exam next to your name.
- Provide your Address, ensuring to include all relevant details.
- Enter your Social Security Number (SSN) in the appropriate field.
- Write your Date of Birth and select your Sex by marking the appropriate box.
- List the Name of Accompanying Person if applicable.
- Detail any Diagnoses/Significant Health Conditions. If you have a medical history summary or chronic health problems list, attach it.
- In the Current Medications section, list each medication along with its Name, Dose, Frequency, Diagnosis, Prescribing Physician, and Date Prescribed. Attach an additional page if necessary.
- Indicate whether the person takes medications independently by checking Yes or No.
- List any Allergies/Sensitivities and any Contraindicated Medications.
- Complete the Immunizations section by providing the dates and types of vaccines received.
- Fill out the Tuberculosis (TB) Screening section with the relevant dates and results.
- In the Other Medical/Lab/Diagnostic Tests section, provide details for any exams and their results.
- Record any Hospitalizations/Surgical Procedures with the Date and Reason.
- Move to Part Two, where you will fill in your Blood Pressure, Pulse, Respirations, Temperature, Height, and Weight.
- Evaluate each system listed in the Evaluation of Systems section. Mark Yes or No for normal findings and provide comments as needed.
- Complete the Vision Screening and Hearing Screening sections, indicating if further evaluation is recommended.
- Fill out the Additional Comments section, including any recommendations for health maintenance and dietary instructions.
- Indicate any Limitations or Restrictions for activities, including whether adaptive equipment is used.
- Note any changes in health status from the previous year.
- Complete the physician information section with the Name, Signature, Date, Address, and Phone Number of the physician.
Annual Physical Examination Example
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: ________________________ |
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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 |
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Specialty |
Prescribed |
Does the person take medications independently? |
Yes |
No |
Allergies/Sensitivities:_______________________________________________________________________________ |
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Contraindicated Medication: _________________________________________________________________________
IMMUNIZATIONS:
Tetanus/Diphtheria (every 10 years):______/_____/______ |
Type administered: _________________________ |
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Hepatitis B: #1 ____/_____/____ |
#2 _____/____/________ |
#3 _____/_____/______ |
Influenza (Flu):_____/_____/_____ |
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Pneumovax: _____/_____/_____ |
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Other: (specify)__________________________________________ |
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TUBERCULOSIS (TB) SCREENING: (every 2 years by Mantoux method; if positive initial chest |
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Date given __________ |
Date read___________ |
Results_____________________________________ |
Chest |
Results________________________________________________________ |
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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) |
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Mammogram: |
Date: _____________ |
Results: ________________________________________________ |
(every 2 years- women ages
Prostate Exam: |
Date: _____________ |
Results:______________________________________________________ |
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(digital |
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Hemoccult |
Date: _____________ |
Results:______________________________________________________ |
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Urinalysis |
Date:______________ |
Results: _________________________________________________ |
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CBC/Differential |
Date:______________ |
Results: ______________________________________________________ |
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Hepatitis B Screening |
Date:______________ |
Results: ______________________________________________________ |
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PSA |
Date:______________ |
Results: ______________________________________________________ |
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Other (specify)___________________________________________Date:______________ |
Results: ________________________________ |
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Other (specify)___________________________________________Date:______________ |
Results: ________________________________ |
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HOSPITALIZATIONS/SURGICAL PROCEDURES:
Date
Reason
Date
Reason
12/11/09, revised 7/24/12
PART TWO: GENERAL PHYSICAL EXAMINATION
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Please complete all information to avoid return visits. |
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Blood Pressure:______ /_______ Pulse:_________ |
Respirations:_________ Temp:_________ Height:_________ |
Weight:_________ |
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EVALUATION OF SYSTEMS |
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System Name |
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Normal Findings? |
Comments/Description |
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Eyes |
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Yes |
No |
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Ears |
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Yes |
No |
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Nose |
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Yes |
No |
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Mouth/Throat |
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Yes |
No |
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Head/Face/Neck |
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Yes |
No |
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Breasts |
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Yes |
No |
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Lungs |
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Yes |
No |
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Cardiovascular |
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Yes |
No |
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Extremities |
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Yes |
No |
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Abdomen |
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Yes |
No |
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Gastrointestinal |
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Yes |
No |
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Musculoskeletal |
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Yes |
No |
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Integumentary |
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Yes |
No |
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Renal/Urinary |
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Yes |
No |
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Reproductive |
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Yes |
No |
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Lymphatic |
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Yes |
No |
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Endocrine |
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Yes |
No |
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Nervous System |
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Yes |
No |
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VISION SCREENING |
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Yes |
No |
Is further evaluation recommended by specialist? |
Yes |
No |
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HEARING SCREENING |
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Yes |
No |
Is further evaluation recommended by specialist? |
Yes |
No |
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ADDITIONAL COMMENTS: |
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Medical history summary reviewed? |
Yes |
No |
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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)
___________________________________________________________________________________________________________ |
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Does this person use adaptive equipment? |
No |
Yes (specify):________________________________________________ |
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Change in health status from previous year? No |
Yes (specify):_________________________________________________ |
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This individual is recommended for ICF/ID level of care? (see attached explanation) Yes |
No |
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Specialty consults recommended? No |
Yes (specify):_________________________________________________________ |
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Seizure Disorder present? No Yes (specify type):__________________________________ Date of Last Seizure: ______________ |
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________________________________ |
_______________________________ |
_________________ |
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Name of Physician (please print) |
Physician’s Signature |
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Date |
Physician Address: _____________________________________________ |
Physician Phone Number: ____________________________ |
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12/11/09, revised 7/24/12
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