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?Yes
Fillable fields180
Avg. time to fill out36 min 49 sec
Other namesannual physical exam form pdf, basic physical form, physical exam form, generic physical exam form

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

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Step 1: Choose the button "Get form here" to open it.

Step 2: You are now capable of change generic physical exam form. You have a wide range of options with our multifunctional toolbar - it's possible to add, remove, or alter the content, highlight the specified areas, as well as carry out various other commands.

For every single part, prepare the content demanded by the system.

physical exam form printable empty fields to fill out

Feel free to provide your information in the area Date read, Type administered: , Does the person take medications, Date: Date: Date: Date: Date:, Results:, Results: , Results, Results, Date: , Date: , and Date.

Finishing physical exam form printable step 2

Provide the key information in the Does the person take medications, Date, Reason, Date, Reason, and 12/11/09 part.

part 3 to completing physical exam form printable

Spell out the rights and obligations of the parties inside the part Blood Pressure: / Pulse:, PPlleeaassee ccoommpplleettee, System Name, Normal Findings, Comments/Description, Yes No Yes No Yes No Yes, Eyes Ears Nose Mouth/Throat, and Is further evaluation recommended.

Filling out physical exam form printable stage 4

End up by reading all these areas and filling them in as required: Yes No Yes No Yes No Yes, Eyes Ears Nose Mouth/Throat, Is further evaluation recommended, Medication added, Special medication considerations, Recommendations for health, Recommendations for manual breast, Recommended diet and special, and Information pertinent to diagnosis.

part 5 to entering details in physical exam form printable

Step 3: Once you press the Done button, your finalized form can be exported to each of your devices or to electronic mail given by you.

Step 4: It's possible to make duplicates of the file tokeep clear of any possible problems. Don't be concerned, we cannot disclose or monitor your details.

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