Adult Physical Form – Fill Out and Use This PDF

The ADULT HISTORY & ANNUAL PHYSICAL FORM has NAME, DOB, Today's Date and MEDICATIONS (including OTC & herbs).

Under MEDICATIONS (including OTC & herbs), write the Name, the Mg. / Dosage and the 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.

Under LOCAL PHARMACY, write the pharmacy and Phone #. Under MAIL ORDER PHARMACY, write the Address, City/ ST/Zip, Phone # and Member ID#.

Under PAST MEDICAL HISTORY, list each condition on lines 1. to 5. with its Date. "Have you ever been hospitalized or had an operation?" YES NO. If yes, please explain with type of surgery and dates.

Under Adult Immunizations Review, please list the Date of your Last Immunizations (write N/A if not applicable): Flu, Pneumonia, Shingles and TDaP (Tetanus, Diptheria & Pertussis).

Under REVIEW OF SYSTEMS, mark (X) if you have any of these conditions currently or in the past, in Present or Past. If no medical complaints, please circle NONE.

1. GENERAL, 6. CARDIOVASCULAR, 9. MUSCULOSKELETAL, 2. HEENT, 3. RESPIRATORY, 8. GASTROINTESTINAL and MALE/Genitourinary.

Under ALLERGIES, circle all that apply: None, Aspirin, Penicillin, Codeine, Metal, Latex or Local Anesthetics, or write Other. If yes, explain the reaction. Anaphylaxis: YES / NO.

Under SOCIAL HISTORY, list each Family / Household member (Everyone who lives in your household) with Name, Birth Year and Relationship. Circle YES or NO for you smoke cigarettes or use other tobacco products, with Type, Age started, Age quit and How many packs per day, and for marijuana, cocaine, or non-prescribed narcotics: if so, please describe. Write how many cups of caffeinated coffee, tea, or carbonated beverage you drink daily and how many beers, mixed drinks, or glasses of wine you have weekly. Under 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 and Age at onset for Alcoholism, Allergies, Diabetes, Tuberculosis, Heart Disease, Stroke, High Blood Pressure, Depression / Anxiety / Bipolar, Suicide, Cancer, High Cholesterol, Thyroid issues and Major medical problems.

Only WOMEN fill in the WOMEN ONLY lines: Dates of last two Periods, Current method of contraception, the Number of previous Pregnancies, Miscarriages, Live Births and Terminations, AGE at Menopause, and the Date of Last PAP Test, Mammogram, Dexascan and Colonoscopy (50+).

Only MEN fill in the MEN ONLY lines: Do you perform monthly testicular self-exams (TSE)? Yes No. Write the Date of Last PSA Test and Date of Last Colonoscopy (50+).