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The Annual Physical Examination form is a crucial tool that helps healthcare providers gather comprehensive information about a patient’s health status before their medical appointment. This form requires patients to provide personal details such as their name, date of birth, and address, ensuring that the provider has accurate records. It also prompts individuals to disclose any significant health conditions, current medications, and allergies, which can significantly influence their care. Immunization history is another key aspect, detailing vaccinations like Tetanus, Hepatitis B, and Influenza, along with dates administered. Additionally, the form includes sections for tuberculosis screening and various medical tests, such as GYN exams and prostate exams, which are essential for preventive health measures. The general physical examination section allows healthcare professionals to assess vital signs and evaluate different body systems, ensuring a thorough check-up. By completing this form accurately, patients can help avoid unnecessary follow-up visits and streamline their healthcare experience, ultimately leading to better health outcomes.

Common mistakes

  1. Incompleteness of Personal Information: One common mistake is leaving out essential personal details such as the date of birth or social security number. This information is crucial for accurate medical records and can lead to delays in processing.

  2. Neglecting to List Current Medications: Many individuals forget to provide a complete list of their current medications. It’s important to include all medications, including over-the-counter drugs and supplements, to ensure safe and effective treatment.

  3. Failure to Update Medical History: Some people do not take the time to update their medical history. This can result in overlooking significant health conditions or recent hospitalizations that may affect their care.

  4. Ignoring Allergies and Sensitivities: Another frequent oversight is failing to disclose any allergies or sensitivities. This information is vital for preventing adverse reactions to medications or treatments during the examination.

Preview - Annual Physical Examination Form

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

Documents used along the form

The Annual Physical Examination form is an essential document that helps healthcare providers assess a patient's overall health. Alongside this form, several other documents are often utilized to ensure comprehensive care and accurate medical records. Below is a list of common forms that complement the Annual Physical Examination form.

  • Medical History Form: This document gathers detailed information about a patient's past medical conditions, surgeries, and family health history. It helps healthcare providers understand risk factors and tailor treatment plans accordingly.
  • Medication List: A current list of all medications a patient is taking, including dosages and frequency. This form is crucial for preventing drug interactions and ensuring safe prescribing practices.
  • Immunization Record: This record details all vaccinations a patient has received, including dates and types of vaccines. It is important for tracking immunization status and ensuring compliance with health recommendations.
  • Mobile Home Bill of Sale: This legal document serves to officially transfer ownership of a mobile home from one party to another, ensuring a smooth transaction process. More details can be found in the Mobile Home Bill of Sale.
  • Consent for Treatment: This form obtains a patient's consent for medical procedures and treatments. It ensures that patients are informed about the risks and benefits of their care.
  • Referral Form: When a patient needs to see a specialist, this form provides necessary information about the patient's condition and the reason for the referral. It facilitates communication between healthcare providers.

These documents work together with the Annual Physical Examination form to create a complete picture of a patient's health, ensuring that they receive the best possible care. Properly completed forms help streamline the healthcare process and enhance patient safety.

Similar forms

The Annual Physical Examination form shares similarities with the Medical History Questionnaire. Both documents gather essential health information about the patient, including past medical history, current medications, and significant health conditions. The Medical History Questionnaire typically focuses on a broader range of health issues, while the Annual Physical Examination form includes specific details about the current examination and tests conducted. Both forms aim to provide healthcare providers with a comprehensive view of the patient's health status, ensuring informed medical decisions can be made during appointments.

The Texas Bill of Sale form is a crucial legal document that records the details of a transaction between a seller and a buyer, specifically the sale and transfer of personal property. It serves as proof of purchase and can be vital for personal records or legal requirements. For those looking to understand the specifics of this form or to formally execute a transaction, you can open the document for further guidance.

Another document akin to the Annual Physical Examination form is the Immunization Record. This record tracks vaccinations administered to an individual over time, detailing the types of vaccines received, dates of administration, and any adverse reactions. Similar to the immunization section of the Annual Physical Examination form, the Immunization Record is crucial for maintaining up-to-date health information. Both documents help healthcare providers assess vaccination needs and ensure compliance with public health guidelines.

The Health Risk Assessment (HRA) is another document that parallels the Annual Physical Examination form. An HRA typically collects information on lifestyle choices, health behaviors, and potential risk factors for various diseases. While the Annual Physical Examination form focuses more on clinical findings and current health status, both documents aim to identify areas for improvement in a patient's health. They serve as tools for healthcare providers to tailor recommendations and interventions based on individual patient needs.

Lastly, the Consent for Treatment form is similar in that it is often completed before a medical appointment. This document ensures that patients understand the procedures they will undergo and agree to the treatment plan. While the Annual Physical Examination form collects health information for the provider's use, the Consent for Treatment form focuses on obtaining the patient's permission for medical interventions. Both documents are essential for fostering effective communication and trust between healthcare providers and patients.

Dos and Don'ts

When filling out the Annual Physical Examination form, it’s important to be thorough and accurate. Here are six things you should and shouldn’t do:

  • Do: Complete all sections of the form to avoid delays in processing.
  • Do: Provide accurate information about your medical history and current medications.
  • Do: List any allergies or sensitivities clearly to ensure proper care.
  • Do: Indicate whether you have had any recent hospitalizations or surgeries.
  • Don’t: Leave any sections blank; incomplete forms may result in a return visit.
  • Don’t: Provide vague answers; be specific about your health conditions and medications.

Key takeaways

Filling out the Annual Physical Examination form is a crucial step in maintaining your health and ensuring a productive visit with your healthcare provider. Here are some key takeaways to keep in mind:

  • Complete Every Section: Ensure that all sections of the form are filled out completely. Missing information can lead to unnecessary follow-up visits.
  • Provide Accurate Medical History: Include a detailed medical history summary and list any chronic health problems. This information is vital for your doctor to understand your health background.
  • List Current Medications: Document all medications you are currently taking, including dosage and frequency. If needed, attach an additional page for more space.
  • Note Allergies: Clearly list any allergies or sensitivities to medications. This helps prevent adverse reactions during treatment.
  • Update Immunization Records: Keep track of your immunizations. Indicate the dates and types of vaccines received, as this information is essential for your overall health assessment.
  • Be Honest About Health Status: If you have experienced changes in your health since your last exam, be open about it. This transparency allows your healthcare provider to offer the best care possible.
  • Follow Up on Recommendations: After your examination, pay attention to any recommendations made by your physician. These may include further tests, lifestyle changes, or referrals to specialists.

By adhering to these guidelines, you can help ensure that your Annual Physical Examination is thorough and beneficial, paving the way for better health outcomes.

How to Use Annual Physical Examination

After completing the Annual Physical Examination form, it will be submitted to the healthcare provider prior to the scheduled appointment. This information is crucial for the provider to prepare for the examination and address any specific health concerns.

  1. Personal Information: Fill in your name, date of exam, address, Social Security Number (SSN), date of birth, and sex (check the appropriate box).
  2. Accompanying Person: Provide the name of the person accompanying you to the appointment.
  3. Medical History: List any diagnoses or significant health conditions. If available, include a summary of your medical history and any chronic health problems.
  4. Current Medications: Write down all medications you are currently taking, including the name, dose, frequency, diagnosis, prescribing physician, and date prescribed. Indicate if you take medications independently.
  5. Allergies/Sensitivities: Note any allergies or sensitivities you have.
  6. Immunizations: Record the dates and types of any immunizations received, including Tetanus/Diphtheria, Hepatitis B, Influenza, Pneumovax, and any others.
  7. Tuberculosis Screening: Provide the date given, date read, and results of the TB screening. Include chest x-ray details if applicable.
  8. Other Medical Tests: List any other medical, lab, or diagnostic tests performed, including dates and results.
  9. Hospitalizations/Surgical Procedures: Document any past hospitalizations or surgeries, including dates and reasons.
  10. General Physical Examination: Complete the section on vital signs, including blood pressure, pulse, respirations, temperature, height, and weight.
  11. Evaluation of Systems: Answer whether the findings for each system are normal or not and provide comments if necessary.
  12. Vision and Hearing Screening: Indicate if further evaluation is recommended for vision and hearing.
  13. Additional Comments: Review your medical history, note any medication changes, and provide recommendations for health maintenance and special instructions.
  14. Limitations or Restrictions: Indicate any limitations or restrictions for activities, including work.
  15. Adaptive Equipment: Specify if you use any adaptive equipment.
  16. Change in Health Status: Note any changes in health status from the previous year.
  17. Physician Information: Print the name of the physician, sign, and date the form. Include the physician's address and phone number.