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The Annual Physical Examination form is an essential tool for both patients and healthcare providers. It collects vital information that helps ensure a thorough evaluation during medical appointments. Before visiting the doctor, patients must complete the first part of the form. This section includes personal details like name, date of birth, and address, as well as a summary of medical history, current medications, and any allergies. Patients also need to provide information on immunizations and any significant health conditions. The second part of the form is focused on the general physical examination. Here, healthcare providers assess various systems of the body, including cardiovascular, respiratory, and musculoskeletal functions. Blood pressure, pulse, and other vital signs are recorded to gauge overall health. Additional sections allow for comments on specific evaluations, recommendations for health maintenance, and any necessary restrictions on activities. Completing this form accurately helps avoid the need for return visits and ensures that the healthcare provider has all the information needed for a comprehensive assessment.
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Steps to Using Annual Physical Examination
Completing the Annual Physical Examination form is straightforward. This form gathers essential health information to ensure a smooth medical appointment. Be thorough and accurate to prevent any delays in your visit.
- Start with PART ONE. Fill in your Name, Date of Exam, and Address.
- Provide your Social Security Number and Date of Birth.
- Indicate your Sex by checking the appropriate box.
- Enter the Name of Accompanying Person if applicable.
- List any Diagnoses/Significant Health Conditions you have. Include a summary of your medical history and chronic health problems if available.
- Document your Current Medications. Include the medication name, dose, frequency, diagnosis, prescribing physician, and date prescribed. Attach a second page if necessary.
- Answer whether you take medications independently by checking Yes or No.
- List any Allergies/Sensitivities you have.
- Note any Contraindicated Medication.
- Fill in your Immunizations dates and types, including Tetanus/Diphtheria, Hepatitis B, Influenza, and Pneumovax.
- Complete the Tuberculosis (TB) Screening section with the date given, date read, and results.
- Answer whether you are free of communicable diseases by checking Yes or No. If no, list precautions.
- List any Other Medical/Lab/Diagnostic Tests performed, including dates and results.
- Document any Hospitalizations/Surgical Procedures with dates and reasons.
- Move to PART TWO. Fill in your Blood Pressure, Pulse, Respirations, Temperature, Height, and Weight.
- Evaluate each system by checking Yes or No for normal findings. Include comments if necessary.
- Complete the Vision Screening and Hearing Screening sections, indicating if further evaluation is recommended.
- Provide any Additional Comments regarding your medical history, medications, recommendations, and special instructions.
- Indicate any limitations or restrictions for activities, checking Yes or No, and specify if applicable.
- Note if you use adaptive equipment, checking Yes or No, and specify if applicable.
- Answer whether there has been a change in health status from the previous year.
- Indicate if you are recommended for ICF/ID level of care, and whether any specialty consults are recommended.
- If applicable, provide details about any seizure disorder, including the date of the last seizure.
- Finally, have the physician print their name, sign, and date the form. Include their address and phone number.
Key takeaways
1. Complete All Sections: Ensure every section of the Annual Physical Examination form is filled out completely. Incomplete forms may lead to delays and additional visits.
2. Provide Accurate Medical History: Include a summary of your medical history and any chronic health problems. This information is crucial for your healthcare provider to offer the best care.
3. List Current Medications: Clearly list all current medications, including dosage and frequency. Attach an additional page if necessary. This helps prevent any medication interactions.
4. Update Immunization Records: Make sure to provide up-to-date immunization dates. This includes vaccines such as Tetanus, Hepatitis B, and Influenza. Accurate records are essential for your health assessment.
5. Report Allergies and Sensitivities: Clearly state any allergies or sensitivities. This information is vital to avoid any adverse reactions during your examination or treatment.
6. Follow Up on Recommendations: After the examination, pay attention to any recommendations provided by your physician. This may include further tests, lifestyle changes, or referrals to specialists.
Misconceptions
There are several misconceptions about the Annual Physical Examination form that can lead to confusion. Here are four common ones:
- It’s only for people with health issues. Many believe that only those with existing health problems need to complete this form. In reality, everyone should fill it out to ensure a comprehensive evaluation of their health.
- All sections must be filled out every year. Some think that every part of the form needs to be completed during each visit. However, certain sections, like immunizations or specific tests, may not apply every year depending on individual health circumstances.
- It’s unnecessary if you feel healthy. There is a belief that if someone feels fine, they don’t need an annual exam. Regular check-ups can catch potential health issues early, even when no symptoms are present.
- The form is only for the doctor’s records. Some assume that the form is solely for the physician's use. In fact, it serves as a tool for patients to track their health history and for healthcare providers to offer better, personalized care.
Preview - 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: ________________________ |
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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 |
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Specialty |
Prescribed |
Does the person take medications independently? |
Yes |
No |
Allergies/Sensitivities:_______________________________________________________________________________ |
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Contraindicated Medication: _________________________________________________________________________
IMMUNIZATIONS:
Tetanus/Diphtheria (every 10 years):______/_____/______ |
Type administered: _________________________ |
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Hepatitis B: #1 ____/_____/____ |
#2 _____/____/________ |
#3 _____/_____/______ |
Influenza (Flu):_____/_____/_____ |
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Pneumovax: _____/_____/_____ |
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Other: (specify)__________________________________________ |
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TUBERCULOSIS (TB) SCREENING: (every 2 years by Mantoux method; if positive initial chest |
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Date given __________ |
Date read___________ |
Results_____________________________________ |
Chest |
Results________________________________________________________ |
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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) |
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Mammogram: |
Date: _____________ |
Results: ________________________________________________ |
(every 2 years- women ages
Prostate Exam: |
Date: _____________ |
Results:______________________________________________________ |
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(digital |
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Hemoccult |
Date: _____________ |
Results:______________________________________________________ |
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Urinalysis |
Date:______________ |
Results: _________________________________________________ |
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CBC/Differential |
Date:______________ |
Results: ______________________________________________________ |
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Hepatitis B Screening |
Date:______________ |
Results: ______________________________________________________ |
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PSA |
Date:______________ |
Results: ______________________________________________________ |
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Other (specify)___________________________________________Date:______________ |
Results: ________________________________ |
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Other (specify)___________________________________________Date:______________ |
Results: ________________________________ |
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HOSPITALIZATIONS/SURGICAL PROCEDURES:
Date
Reason
Date
Reason
12/11/09, revised 7/24/12
PART TWO: GENERAL PHYSICAL EXAMINATION
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Please complete all information to avoid return visits. |
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Blood Pressure:______ /_______ Pulse:_________ |
Respirations:_________ Temp:_________ Height:_________ |
Weight:_________ |
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EVALUATION OF SYSTEMS |
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System Name |
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Normal Findings? |
Comments/Description |
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Eyes |
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Yes |
No |
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Ears |
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Yes |
No |
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Nose |
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Yes |
No |
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Mouth/Throat |
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Yes |
No |
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Head/Face/Neck |
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Yes |
No |
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Breasts |
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Yes |
No |
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Lungs |
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Yes |
No |
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Cardiovascular |
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Yes |
No |
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Extremities |
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Yes |
No |
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Abdomen |
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Yes |
No |
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Gastrointestinal |
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Yes |
No |
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Musculoskeletal |
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Yes |
No |
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Integumentary |
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Yes |
No |
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Renal/Urinary |
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Yes |
No |
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Reproductive |
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Yes |
No |
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Lymphatic |
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Yes |
No |
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Endocrine |
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Yes |
No |
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Nervous System |
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Yes |
No |
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VISION SCREENING |
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Yes |
No |
Is further evaluation recommended by specialist? |
Yes |
No |
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HEARING SCREENING |
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Yes |
No |
Is further evaluation recommended by specialist? |
Yes |
No |
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ADDITIONAL COMMENTS: |
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Medical history summary reviewed? |
Yes |
No |
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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)
___________________________________________________________________________________________________________ |
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Does this person use adaptive equipment? |
No |
Yes (specify):________________________________________________ |
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Change in health status from previous year? No |
Yes (specify):_________________________________________________ |
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This individual is recommended for ICF/ID level of care? (see attached explanation) Yes |
No |
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Specialty consults recommended? No |
Yes (specify):_________________________________________________________ |
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Seizure Disorder present? No Yes (specify type):__________________________________ Date of Last Seizure: ______________ |
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________________________________ |
_______________________________ |
_________________ |
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Name of Physician (please print) |
Physician’s Signature |
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Date |
Physician Address: _____________________________________________ |
Physician Phone Number: ____________________________ |
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12/11/09, revised 7/24/12
Document Specs
| Fact Name | Description |
|---|---|
| Purpose | The Annual Physical Examination form is designed to collect comprehensive health information before a medical appointment. |
| Completion Requirement | Patients must complete all sections to avoid the need for return visits. |
| Personal Information | Basic details such as name, date of birth, and social security number are required for identification. |
| Medical History | Patients are encouraged to provide a summary of significant health conditions and a list of chronic health problems. |
| Medication Disclosure | Current medications, including dosage and prescribing physician, must be documented. This helps in assessing potential interactions. |
| Immunization Records | Patients should list their immunizations, including dates for Tetanus, Hepatitis B, and Influenza vaccines. |
| TB Screening | Screening for tuberculosis is required every two years, with specific follow-up actions if results are positive. |
| Evaluation of Systems | A comprehensive evaluation of various body systems is conducted, with space for normal findings and additional comments. |
| Health Recommendations | Recommendations for health maintenance, including lab work and lifestyle changes, are provided based on the examination. |
| State-Specific Laws | Each state may have specific laws governing the use of such forms, including privacy regulations under HIPAA. |