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The Annual Physical Examination Form is a crucial document that gathers essential health information prior to a medical appointment. This form helps healthcare providers assess your medical history, current medications, and any significant health conditions, ensuring a comprehensive evaluation during your visit. To facilitate a smooth process, it is important to fill out this form completely before your appointment.

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Table of Contents

Form Overview

Fact Name	Details
Purpose	The Annual Physical Examination form is designed to collect comprehensive health information before a medical appointment.
Personal Information	Patients must provide their name, date of exam, address, Social Security number, date of birth, and sex.
Medication Disclosure	Patients are required to list current medications, including dosage, frequency, diagnosis, and prescribing physician.
Immunization Records	The form includes sections for documenting immunizations, such as Tetanus, Hepatitis B, and Influenza.
Health Screening	Tuberculosis screening is mandated every two years using the Mantoux method, with specific follow-up actions if results are positive.
Medical History	Patients must provide a summary of significant health conditions and past hospitalizations or surgical procedures.
Evaluation of Systems	A general physical examination is conducted, assessing various body systems, including cardiovascular and respiratory health.
Legal Compliance	In some states, the use of this form is governed by specific health care regulations that mandate the collection of such information.

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Documents used along the form

The Annual Physical Examination form is essential for gathering comprehensive health information. However, there are several other documents that often accompany it to ensure a complete assessment of an individual's health status. Here’s a brief overview of those documents.

Medical History Form: This form collects detailed information about past medical issues, surgeries, and family health history. It helps healthcare providers understand risk factors and previous conditions.
Consent for Treatment: Patients sign this document to give permission for medical examinations and treatments. It clarifies what procedures may be performed during the visit.
Immunization Record: This document lists all vaccinations a patient has received. It is important for tracking immunization status and ensuring compliance with health guidelines.
Medication List: A detailed account of all current medications, including dosages and prescribing physicians. This helps avoid potential drug interactions and ensures safe prescribing.
Referral Form: If a specialist's evaluation is necessary, this form provides the required information for the referral process. It includes the reason for the referral and any relevant medical history.
Lab Test Orders: These orders specify any laboratory tests needed during the examination. They ensure that the necessary tests are performed to assess the patient’s health accurately.
Follow-Up Care Instructions: After the examination, this document outlines any recommended next steps, including additional tests, referrals, or lifestyle changes. It helps patients understand their ongoing care needs.

Using these documents together with the Annual Physical Examination form creates a clearer picture of a patient's health. This comprehensive approach allows healthcare providers to offer the best possible care and support for their patients.

Document Sample

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