Annual Physical Form PDF Details

This form confirms that a provider properly documented an annual medical exam. In many care and residential settings, it becomes the primary record that shows compliance with health review requirements.

Agencies, providers, and reviewers often rely on the annual physical exam form to verify eligibility for services or check whether follow-up care is needed. Because of this, the way you complete this document affects both care planning and administrative timelines.

The layout follows the flow of a real appointment. Information collected before the visit gives the physician context on diagnoses, medications, and prior treatment. The examination section then records vital signs, system reviews, screening results, and clinical observations made during the visit. This structure makes it easier to compare current findings with prior years.

Reviewers examine certain sections more closely because those sections directly affect service decisions:

✔️ How medications are listed and whether the person manages them independently.

✔️ Immunization records and tuberculosis screening results.

✔️ Notes on communicable diseases and required precautions.

✔️ Documented activity limits or use of adaptive equipment.

✔️ Physician recommendations related to level of care or referrals.

From an administrative standpoint, the annual physical examination form becomes written proof that a licensed physician evaluated the individual and signed off on the findings.

A licensed physician completes the form during the annual medical exam. The individual, caregiver, or service provider fills out the background sections before the visit. Then, the physician records the examination findings and signs the form.

QuestionAnswer
Form Name Annual Physical Exam Form PDF
Form Length 2 pages
Fillable? Yes
Fillable fields 110
Avg. time to fill out 20 min
Other names general physical examination form PDF, form for physical exam, basic physical form, basic physical exam form PDF

Form Preview 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: ________________________

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

How to Edit Annual Physical Examination Form Online for Free

Follow the steps below to properly complete this annual physical examination form in PDF format.

portion of empty spaces in physical exam form

1. Pre-Appointment Section

Start with Part One before the medical visit:

  • Fill in the individual’s name, address, date of birth, exam date, and other identifying details.
  • From there, list current diagnoses and health conditions, along with medications, allergies, and any contraindicated medications.
  • After that, add immunization dates, tuberculosis screening results, and information about past hospitalizations or surgeries.

If something does not apply, make that clear instead of leaving the space blank.

part 2 to finishing physical exam form

2. Supporting Details

Before the appointment, review medication lists, lab results, and prior records for accuracy. Add extra pages if the medication or medical history sections need more space.

Double-check dates and prescribing details, since even small inconsistencies can lead to follow-up requests from agencies or reviewers.

Completing physical exam form stage 3

3. Physical Examination

During the appointment, the physician completes Part Two of this annual physical exam form template. This section covers vital signs, system-by-system findings, vision and hearing screenings, and any relevant comments.

The physician should note any changes since the prior year, record activity limits or use of adaptive equipment, and clearly document recommendations for care, referrals, or follow-up.

physical exam form PPlleeaassee ccoommpplleettee, Blood Pressure  Pulse Respirations, EVALUATION OF SYSTEMS, System Name, Eyes Ears Nose MouthThroat, Additional Comments, Normal Findings Yes No Yes No Yes, CommentsDescription, Is further evaluation recommended, and Medical history summary reviewed blanks to fill out

4. Required Certifications

The physician should answer every yes-or-no question related to health status, level of care, specialty consults, and seizure disorders when applicable.

Each response must align with the clinical notes to avoid conflicting or unclear information.

stage 5 to filling out physical exam form

5. Final Part

The physician should print and sign their name, add the date, and include contact information.

Keep the completed form on file as part of the individual’s medical record.

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