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Contents

The Annual Physical Examination form serves as a comprehensive tool designed to facilitate a thorough assessment of an individual's health status. It is essential for patients to complete all sections of the form prior to their medical appointment to minimize the need for return visits. The first part of the form requires personal information, including the patient's name, date of birth, and medical history, as well as details about current medications and any allergies. This section also covers immunization records, tuberculosis screening, and a list of any significant health conditions. The second part of the form focuses on the general physical examination, where vital signs such as blood pressure, pulse, and temperature are recorded. A systematic evaluation of various body systems follows, allowing healthcare providers to note any normal findings or areas requiring further attention. Additional comments can include recommendations for health maintenance, dietary instructions, and any limitations on activities. By gathering this information, the Annual Physical Examination form not only streamlines the examination process but also ensures that healthcare providers have a clear understanding of each patient's unique health needs.

How to Write Annual Physical Examination

Once you have gathered all necessary information, you can begin filling out the Annual Physical Examination form. Make sure to complete all sections to avoid any delays or return visits.

  1. Personal Information: Fill in your name, date of exam, address, Social Security Number (SSN), date of birth, and sex. If applicable, include the name of the person accompanying you.
  2. Medical History: List any diagnoses or significant health conditions. Include a summary of your medical history and any chronic health problems if available.
  3. Current Medications: Provide details about your current medications, including the name, dose, frequency, diagnosis, prescribing physician, and specialty prescribed. Indicate whether you take medications independently and list any allergies or sensitivities.
  4. Immunizations: Record the dates and types of immunizations received, such as Tetanus/Diphtheria, Hepatitis B, Influenza, and Pneumovax. If there are other immunizations, specify them as well.
  5. Tuberculosis Screening: Note the date the TB test was given and read, along with the results. If applicable, include the date and results of any chest x-ray.
  6. Other Medical Tests: Document any additional medical, lab, or diagnostic tests, including GYN exams, mammograms, prostate exams, and others, along with their dates and results.
  7. Hospitalizations/Surgical Procedures: List any hospitalizations or surgical procedures, including the date and reason for each.
  8. General Physical Examination: Fill in your blood pressure, pulse, respirations, temperature, height, and weight.
  9. Evaluation of Systems: Indicate whether normal findings were observed for each system listed (e.g., eyes, ears, lungs, etc.) and provide comments if necessary.
  10. Vision and Hearing Screening: Indicate whether screenings were conducted and if further evaluation is recommended.
  11. Additional Comments: Provide any additional comments, including medical history reviews, medication changes, recommendations for health maintenance, and dietary instructions.
  12. Limitations or Restrictions: Note any limitations or restrictions for activities, and specify if adaptive equipment is used.
  13. Change in Health Status: Indicate if there has been a change in health status from the previous year.
  14. Physician Information: Print the name of the physician, sign, and date the form. Include the physician's address and phone number.

Misconceptions

Here are seven misconceptions about the Annual Physical Examination form:

  • It is only for sick individuals. Many people believe that an annual physical examination is only necessary if they are experiencing health issues. In reality, these exams are important for preventive care and monitoring overall health, regardless of current health status.
  • Completing the form is optional. Some individuals think that filling out the Annual Physical Examination form is not mandatory. However, providing complete and accurate information is essential to ensure the healthcare provider can offer the best care possible.
  • Only the doctor reviews the form. While the physician does review the form, other healthcare staff may also use the information to prepare for the appointment and provide appropriate care.
  • All information must be filled out in detail. It is a misconception that every section must have extensive details. While it is important to provide relevant information, some sections may require only brief responses.
  • The form is the same for everyone. Some believe that the Annual Physical Examination form is a one-size-fits-all document. In fact, the form may vary based on the individual’s age, gender, and specific health needs.
  • It is not necessary to update medication information. Individuals may think that once they provide their medication list, it does not need to be updated. However, any changes in medications should be reported at each visit to ensure accurate medical care.
  • The form is only relevant for adults. Many people assume that the Annual Physical Examination form is designed solely for adults. In truth, children and adolescents also benefit from regular physical examinations and may require similar forms tailored to their needs.

Annual Physical Examination 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

Key takeaways

Filling out the Annual Physical Examination form accurately is crucial for ensuring a smooth and efficient medical appointment. Here are five key takeaways to keep in mind:

  • Complete All Sections: Make sure to fill out every section of the form. Missing information can lead to delays and additional visits.
  • List Current Medications: Provide a detailed list of all medications, including dosages and prescribing physicians. This helps your healthcare provider understand your medical history better.
  • Note Allergies: Clearly indicate any allergies or sensitivities you have. This information is vital for your safety during examinations and treatments.
  • Update Medical History: Include any recent hospitalizations, surgeries, or changes in health status. This helps your physician tailor their evaluation to your current needs.
  • Follow Up on Recommendations: After your examination, pay close attention to any recommendations for follow-up tests or lifestyle changes. Implementing these suggestions can significantly improve your health.

By keeping these takeaways in mind, you can make the most out of your annual physical examination and ensure that your healthcare provider has all the necessary information to assist you effectively.

Dos and Don'ts

When filling out the Annual Physical Examination form, it is important to ensure accuracy and completeness. Here are seven essential tips to keep in mind:

  • Do provide all requested personal information, including your name, date of birth, and address.
  • Do list any current medications you are taking, including the name, dose, and prescribing physician.
  • Do indicate any allergies or sensitivities you have to medications or substances.
  • Do ensure that all sections of the form are filled out, especially the health history and immunization records.
  • Don’t leave any questions unanswered; this can lead to delays or the need for additional visits.
  • Don’t forget to sign and date the form before submitting it to your physician.
  • Don’t provide incomplete information about past hospitalizations or surgeries, as this is crucial for your medical history.

Following these guidelines will help ensure that your Annual Physical Examination goes smoothly and that your healthcare provider has all the necessary information to assist you effectively.

Similar forms

The Health History Questionnaire serves a similar purpose to the Annual Physical Examination form by collecting detailed information about an individual's medical background. It typically includes sections for personal information, medical history, current medications, allergies, and family medical history. Both documents aim to ensure that healthcare providers have a comprehensive understanding of a patient's health status before conducting an examination or treatment.

The Patient Intake Form is another document that shares similarities with the Annual Physical Examination form. This form is often used in medical offices to gather essential information from new patients. It includes sections for personal details, insurance information, medical history, and current medications. Like the Annual Physical Examination form, it seeks to streamline the process of obtaining relevant health information prior to a medical appointment.

The Medication Reconciliation Form is closely related to the Annual Physical Examination form, particularly in its focus on current medications. This document is used to compare a patient's medication list against their current prescriptions to identify any discrepancies or potential interactions. Both forms emphasize the importance of accurate medication information for safe and effective healthcare delivery.

The Immunization Record is another document that parallels the Annual Physical Examination form. It tracks a patient's vaccination history, including dates and types of immunizations received. Both documents play a crucial role in ensuring that individuals are up to date on necessary vaccinations, which is vital for preventive health measures.

The Lab Test Requisition Form is similar to the Annual Physical Examination form in that it specifies tests that need to be performed based on a patient's health status. This form typically includes patient information, the specific tests ordered, and any relevant clinical information. Both documents are essential for guiding healthcare providers in assessing a patient's health through diagnostic testing.

The Consent for Treatment Form is another document that serves a similar function to the Annual Physical Examination form. It ensures that patients understand and agree to the procedures and examinations they will undergo. Both documents are critical for establishing clear communication between patients and healthcare providers, fostering informed consent.

The Medical Release Form is akin to the Annual Physical Examination form in that it allows healthcare providers to share a patient’s medical information with other parties, such as specialists or insurance companies. Both documents facilitate the flow of essential health information, which is vital for coordinated care and treatment planning.

For individuals looking to prepare their legal documents, the Last Will and Testament serves a similar purpose to the Annual Physical Examination form by ensuring that important aspects of one’s life are documented comprehensively. It emphasizes the significance of clear instruction regarding asset distribution after death, providing assurance that one’s wishes will be respected. For more information on how to create your Last Will and Testament, you can visit pdfdocshub.com/.

The Advance Directive Form shares similarities with the Annual Physical Examination form by addressing a patient's preferences for medical treatment in the event they are unable to communicate their wishes. Both documents focus on the patient's health and well-being, ensuring that their values and preferences are respected in medical decision-making.

The Follow-Up Appointment Form is another document that is similar to the Annual Physical Examination form. It is used to schedule and confirm subsequent visits based on the findings from the initial examination. Both documents aim to enhance continuity of care by ensuring that patients receive appropriate follow-up for any identified health concerns.

Finally, the Chronic Disease Management Plan is closely related to the Annual Physical Examination form. This document outlines a strategy for managing ongoing health conditions, including medications, lifestyle changes, and regular monitoring. Both documents emphasize proactive health management to improve patient outcomes and quality of life.