Annual Physical Examination Form PDF Details

The Annual Physical Examination Form is a document that contains personal health information and history. It includes the name, date of birth, gender, race/ethnicity, height and weight of the patient as well as their social security number. The form also includes questions about medical history such as allergies or current medications. A signed consent form must be submitted before an examination can take place. The Annual Physical Examination Form was created to serve many purposes including: 1) providing documentation for billing insurance companies; 2) collecting data for public health surveillance reports; 3) identifying potential risk factors for chronic diseases; 4) evaluating progress in meeting goals set by national guidelines (e.g.

This general guide will aid you to ascertain how long it'll require you to fill out annual physical examination form, how many pages it has, and some additional specific specifics of the form.

QuestionAnswer
Form NameAnnual Physical Examination Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesgeneral 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

We were making the PDF editor having the idea of making it as effortless to use as it can be. Therefore the process of typing in the physical exam form printable will be effortless as you go through these actions:

Step 1: Hit the "Get Form Now" button to get going.

Step 2: The document editing page is presently open. You can add text or enhance present data.

The PDF template you decide to fill in will consist of the following areas:

portion of empty spaces in physical exam form

Note the data in IMMUNIZATIONS TetanusDiphtheria, Type administered, TUBERCULOSIS TB SCREENING every, Date read, Results, Is the person free of communicable, Date, Date, Results, OTHER MEDICALLABDIAGNOSTIC TESTS, Date Date Date Date Date, Results, Results, and Date.

part 2 to finishing physical exam form

Identify the most significant details about the OTHER MEDICALLABDIAGNOSTIC TESTS, Date Date Date Date Date, HOSPITALIZATIONSSURGICAL PROCEDURES, Date, Reason, Date, Reason, and revised field.

Completing physical exam form stage 3

The 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 field enables you to point out the rights and responsibilities of both sides.

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

End up by reading these fields and filling them in accordingly: Medical history summary reviewed, Special medication considerations, Recommendations for health, Recommendations for manual breast, Recommended diet and special, Information pertinent to diagnosis, Limitations or restrictions for, Does this person use adaptive, Change in health status from, This individual is recommended for, Specialty consults recommended No, Seizure Disorder present No Yes, Name of Physician please print, Date, and Physicians Signature.

stage 5 to filling out physical exam form

Step 3: Select the "Done" button. Now you may export your PDF form to your device. As well as that, it is possible to forward it through email.

Step 4: To prevent yourself from any sort of headaches in the long run, try to get at the very least a couple of copies of your form.

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