Adult Physical Form PDF Details

Understanding the comprehensive scope of an Adult Physical Form is crucial for maintaining an individual's health and wellness. This form, available through platforms like www.familywellnesscntr.com, encompasses a wide array of information—ranging from personal identification details, such as name and date of birth, to an extensive medical history including medications, both prescribed and over-the-counter, along with dosage and reasons for their use. It prompts individuals to list local and mail-order pharmacies for ease of medication access. The form delves deep into past medical history, with space for detailing previous hospitalizations and operations, while also addressing adult immunizations and reviewing systems to identify past and present health conditions across various health spectrums. Allergies, social history, including tobacco and alcohol use, and family medical history are crucial parts for creating a comprehensive health overview. Specific sections dedicated to women and men ensure gender-specific health issues are not overlooked, requesting information on reproductive health, cancer screenings, and more. This careful compilation of health data aids medical professionals in offering personalized, effective care, making the Adult Physical Form a critical tool in managing one's health journey.

QuestionAnswer
Form NameAdult Physical Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesadult physical exam form pdf, physical forms printable, generic physical form pdf, annual physical form blank

Form Preview Example

ADULT HISTORY & ANNUAL PHYSICAL FORM www.familywellnesscntr.com

NAME ______________________ DOB ____________________ Today’s Date ______________

MEDICATIONS (including OTC & herbs):

Name:

Mg. / Dosage

Reason why you are taking?

If you have more medications or medical history than can fit on form, please write on back of this form.

LOCAL PHARMACY:

Phone #:

MAIL ORDER PHARMACY:

Address:

City/ ST/Zip:

Phone #:

Member ID#:

PAST MEDICAL HISTORY Date

1.

2.

3.

4.

5.

Have you ever been hospitalized or had an operation? YES NO If yes, please explain with type of surgery and dates: _______________________________________________________________________________________________

Adult Immunizations Review – Please list the Date of your Last Immunizations (write N/A if not applicable):

Flu: ________ Pneumonia: ________ Shingles: _________ TDaP (Tetanus, Diptheria & Pertussis):_))_____________

REVIEW OF SYSTEMS:

Mark (X) if you have any of these conditions currently or in the past. If no medical complaints please circle: NONE

 

 

 

 

Present

Past

 

Present

Past

 

 

 

 

 

 

 

 

Present

Past

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. GENERAL:

 

 

 

6. CARDIOVASCULAR

:

 

 

 

 

9. MUSCULOSKELETAL:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weight loss

 

 

 

 

Chest Pain

 

 

 

Joint Pain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fatigue

 

 

 

 

Irregular Heart Beat

 

 

 

Joint Swelling

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Memory Loss

 

 

 

 

Elevated Blood Pressure

 

 

 

Jaw Pain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart Disease

 

 

 

10

. NEUROLOGICAL

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. HEENT:

 

 

 

 

Shortness of Breath

 

 

 

Blackouts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Headache

 

 

 

 

Swelling of Limbs

 

 

 

Dizziness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Visual Loss

 

 

 

 

 

 

 

 

 

 

 

Seizures

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Decreased Hearing

 

 

 

7. ENDOCRINOLOGY

:

 

 

 

 

Stroke

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sinus Pain

 

 

 

 

Diabetes

 

 

 

11.

PSYCHIATRIC:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hoarseness

 

 

 

 

Excessive Thirst

 

 

 

Anxiety

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sore Throat

 

 

 

 

Excessive Urination

 

 

 

Depression

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trouble Swallowing

 

 

 

 

Libido Change

 

 

 

Sleep Issues

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. RESPIRATORY:

 

 

 

8.

GASTROINTESTINAL

:

 

 

 

MALE/Genitourinary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cough

 

 

 

Bloody Stool

 

 

 

Urinary dribbling

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wheezing

 

 

 

 

Constipation

 

 

 

Reduced flow

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. BREAST:

 

 

 

 

Diarrhea

 

 

 

Nighttime urination

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Breast Mass

 

 

 

 

Heart Burn

 

 

 

FEMALE / Genitourinary

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Breast Pain

 

 

 

 

Jaundice

 

 

 

Abnormal PAP smear

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin Changes

 

 

 

 

Kidney Stones

 

 

 

Urinary Complaints

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

. HEMATOLOGY

:

 

 

 

Nausea

 

 

 

Blood in Urine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anemia

 

 

 

Vomiting

 

 

 

Menstrual Irregularities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bleeding Issues

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALLERGIES: Are you allergic to any of the following? (Circle all that apply) None Aspirin Penicillin

Codeine

Metal Latex Local Anesthetics

Other: ______________________________________________________________

If yes, explain the reaction: ___________________________________________________ Anaphylaxis:

YES / NO

SOCIAL HISTORY:

 

 

 

 

 

 

Family / Household member (Everyone who lives in your household):

 

 

Name

 

 

Birth Year

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you EVER or do you smoke cigarettes or use other tobacco products? (please circle)

YES NO

Type:_______________

 

 

 

 

Age started ___________

Age quit ______________

How many packs per day? ____________

Do you use any marijuana, cocaine, or non-prescribed narcotics? (please circle)

YES

NO

If so, please describe: __________________________________________________________________________

How many cups of caffeinated coffee, tea, or carbonated beverage do you drink daily? __________________________

How many beers, mixed drinks, or glasses of wine do you have weekly? _______________________________________

FAMILY HISTORY:

Please check if Mother, Father, Brother/Sister or Grandparents have had any of the following: For Grandparents, please indicate M for Mother’s side of family or P for Father’s side of family.

Mother Father Brother/Sister Grandmother Grandfather

Age at onset

Alcoholism

Allergies

Diabetes

Tuberculosis

Heart Disease

Stroke

High Blood Pressure

Depression / Anxiety / Bipolar

Suicide

Cancer

High Cholesterol

Thyroid issues

Major medical problems

WOMEN ONLY

Dates of last two Periods ____________ ___________

Current method of contraception ______________________

Number of previous:

 

 

Pregnancies _______________

Miscarriages __________

Live Births ________________

Terminations __________

AGE at Menopause _______________

Date of Last: PAP Test:

________________________

Mammogram: ________________________

Dexascan:

________________________

Colonoscopy (50+): ___________________

MEN ONLY

Do you perform monthly testicular self-exams (TSE)?

YesNo

Date of Last PSA Test:_____________________

Date of Last Colonoscopy (50+) _____________________

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Part no. 1 in completing adult physical exam form pdf

2. The next part would be to fill in the next few fields: City STZip, Phone Member ID, Have you ever been hospitalized or, Adult Immunizations Review Please, GENERAL, Weight loss, Fatigue, Memory Loss, HEENT, Headache, Visual Loss, Decreased Hearing, Sinus Pain, Present Past, and CARDIOVASCULAR.

adult physical exam form pdf conclusion process explained (portion 2)

3. This next portion is all about Hoarseness, Sore Throat, Trouble Swallowing, RESPIRATORY, Cough, Wheezing, BREAST, Breast Mass, Breast Pain, Skin Changes, HEMATOLOGY, Anemia, Bleeding Issues, Excessive Thirst, and Excessive Urination - fill out every one of these empty form fields.

Filling out part 3 in adult physical exam form pdf

It's easy to make errors while filling in the Breast Mass, and so make sure you take a second look before you finalize the form.

4. To go ahead, the next stage involves filling in a couple of form blanks. Included in these are ALLERGIES Are you allergic to any, Name, Birth Year Relationship, Age quit , How many packs per day , and Did you EVER or do you smoke, which are essential to continuing with this PDF.

adult physical exam form pdf completion process clarified (stage 4)

5. Because you approach the final sections of this file, you will find just a few more things to undertake. Notably, Did you EVER or do you smoke, Mother Father BrotherSister, Age at onset, WOMEN ONLY, Dates of last two Periods Current, MEN ONLY, Do you perform monthly testicular, and Yes should all be filled out.

adult physical exam form pdf conclusion process outlined (portion 5)

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