Fill Out a Valid Annual Physical Examination Form

The Annual Physical Examination Form is a crucial document used to gather important health information before a medical appointment. This form helps ensure that all necessary details are collected to provide comprehensive care. Completing it accurately can prevent the need for additional visits and facilitate better communication between the patient and healthcare provider.

Access This Annual Physical Examination Now

The Annual Physical Examination form serves as a comprehensive tool for gathering essential health information prior to a medical appointment. Patients are required to fill out personal details, including their name, date of birth, and contact information, which helps healthcare providers understand their background. The form includes a section for documenting significant health conditions and a detailed list of current medications, allowing doctors to review any potential interactions or allergies. Immunization history is also recorded, ensuring that patients are up to date with their vaccinations. Additionally, the form addresses tuberculosis screening and other medical tests, such as GYN exams for women and prostate exams for men, which are crucial for preventive care. A general physical examination section captures vital signs like blood pressure and pulse, along with an evaluation of various body systems. Finally, the form concludes with recommendations for health maintenance and any necessary follow-ups, emphasizing the importance of ongoing health management.

Dos and Don'ts

When filling out the Annual Physical Examination form, attention to detail is crucial. Here are some tips to ensure a smooth process:

Do fill in all personal information completely, including your name, address, and date of birth.
Don't leave any sections blank. Missing information may lead to delays or the need for additional visits.
Do provide a detailed list of current medications, including dosages and prescribing physicians.
Don't forget to mention any allergies or sensitivities, as this information is vital for your care.
Do keep a record of your immunizations, including dates and types administered.
Don't overlook the importance of past medical history, including surgeries or hospitalizations.
Do check that all health conditions are accurately described, especially chronic issues.
Don't hesitate to ask for help if you’re unsure about any part of the form.
Do review the completed form before submitting it to ensure accuracy.

By following these guidelines, you can help ensure that your examination goes smoothly and that your healthcare provider has all the necessary information to assist you effectively.

Key takeaways

Completing the Annual Physical Examination form accurately is crucial for ensuring a smooth medical appointment. Here are five key takeaways regarding its use:

Complete All Sections: Fill out every section of the form, including personal information, medical history, and current medications. Incomplete forms may lead to delays or the need for additional visits.
Update Medical History: Provide a comprehensive summary of any significant health conditions and chronic problems. This information helps healthcare providers make informed decisions about care.
List Current Medications: Include all medications, their dosages, and prescribing physicians. Indicate whether the individual takes medications independently, as this can affect treatment plans.
Document Immunizations: Record all immunizations received, including dates and types. This is essential for maintaining health records and ensuring compliance with vaccination schedules.
Review Recommendations: After the examination, carefully consider any recommendations provided by the physician. This may include follow-up tests, lifestyle changes, or specialist referrals.

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Example - Annual Physical Examination Form

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

Misconceptions

Misconceptions about the Annual Physical Examination form can lead to confusion and incomplete submissions. Here are six common misunderstandings:

All sections must be completed for every appointment. While it is important to provide as much information as possible, not every section is required for every visit. For example, if certain tests or screenings were not applicable, those can be left blank.
Only new patients need to fill out the form. Existing patients also need to complete the form at each annual visit. This ensures that healthcare providers have the most current information about a patient’s health status and any changes since their last visit.
Providing medication information is optional. It is crucial to list all current medications, including over-the-counter drugs and supplements. This helps prevent any potential drug interactions and allows for better treatment decisions.
Immunization records are not necessary. Immunization history is an important part of the examination. It is essential to include details about past immunizations to ensure proper preventive care is administered.
Health conditions do not need to be detailed. Patients should provide a summary of significant health conditions and any chronic issues. This information helps the physician tailor the examination and recommendations to the patient’s specific needs.
Only the physician reviews the form. In many cases, other healthcare staff may also review the form prior to the appointment. This allows for any necessary follow-up questions to be prepared in advance.

Similar forms

Medical History Form: Similar to the Annual Physical Examination form, the Medical History Form collects comprehensive details about a patient's past and present health conditions. It typically includes sections for chronic illnesses, surgeries, allergies, and family medical history, providing a holistic view of the patient's health.
Patient Intake Form: This document gathers essential information from patients before their first visit. It often includes personal details, insurance information, and health concerns, akin to the initial data collection in the Annual Physical Examination form.
Immunization Record: Like the immunization section of the Annual Physical Examination form, an Immunization Record tracks vaccinations a patient has received. It serves to ensure that patients are up to date on necessary immunizations for their age and health status.
Lab Test Requisition Form: This form is used to order various laboratory tests. It shares similarities with the Annual Physical Examination form in that it includes sections for patient information and specific tests required, ensuring clarity and accuracy in testing.
Medication Reconciliation Form: This document is designed to verify a patient's current medications and dosages. It parallels the medication section of the Annual Physical Examination form, aiming to prevent medication errors and ensure safe prescribing practices.
Referral Form: A Referral Form is used to direct patients to specialists. It often includes patient details and reasons for referral, similar to the specialty consults section in the Annual Physical Examination form, which aims to ensure continuity of care.