Free Annual Physical Examination Template in PDF Get Your Form

Free Annual Physical Examination Template in PDF

The Annual Physical Examination Form is a document designed to collect essential health information prior to a medical appointment. This form helps ensure that all relevant medical history, current medications, and health conditions are accurately recorded, facilitating a comprehensive evaluation by healthcare providers. Completing this form thoroughly can minimize the need for return visits and enhance the quality of care received.

Please fill out the form by clicking the button below.

Get Your Form

Misconceptions

Misconceptions about the Annual Physical Examination form can lead to confusion and missed opportunities for important health assessments. Here are nine common misconceptions clarified:

  • Only children need annual physicals. Many adults also require regular physical examinations to monitor their health and catch potential issues early.
  • The form is optional. Completing the Annual Physical Examination form is essential for providing your healthcare provider with necessary information about your health history and current conditions.
  • All information must be completed in detail. While comprehensive information is helpful, it is more important to provide accurate details about significant health conditions and current medications.
  • Immunizations are not important for adults. Adults should keep their immunizations up to date, including vaccines like Tetanus and Influenza, to protect their health.
  • The physical exam is just a formality. The examination is a vital opportunity to assess your overall health, discuss concerns, and receive personalized recommendations.
  • Only symptoms need to be reported. It is equally important to provide a complete medical history, including any chronic conditions or medications, even if they seem unrelated to current symptoms.
  • Lab tests are optional. Depending on your age, sex, and medical history, certain lab tests may be necessary to ensure a thorough evaluation of your health.
  • Results will be provided immediately. Some tests may take time to process, and your healthcare provider will communicate results as they become available.
  • Once the form is submitted, no further action is needed. It is important to follow up on any recommendations or referrals provided during your examination to maintain your health.

Documents used along the form

When preparing for an annual physical examination, several forms and documents may accompany the main examination form. Each of these documents serves a specific purpose in ensuring comprehensive care and accurate medical history. Below is a list of common forms that you might encounter.

  • Medical History Questionnaire: This form collects detailed information about past medical conditions, surgeries, allergies, and family health history. It helps healthcare providers understand a patient’s background and potential risk factors.
  • Consent for Treatment: This document ensures that patients understand and agree to the procedures and treatments they may receive during their visit. It protects both the patient and the provider by establishing informed consent.
  • Immunization Records: This record lists all vaccinations a patient has received. It is crucial for assessing immunity levels and determining any necessary booster shots.
  • Medication List: Patients are often asked to provide a comprehensive list of current medications, including dosages and frequency. This helps prevent drug interactions and ensures safe prescribing practices.
  • Lab Test Orders: If specific tests are required during the physical examination, this form outlines which tests need to be conducted. It streamlines the process for both the patient and the laboratory.
  • Referral Forms: Should a specialist consultation be necessary, this document facilitates the referral process. It typically includes the patient’s information and the reason for the referral.
  • Patient Registration Form: This form collects essential demographic information, including contact details and insurance information, to maintain accurate records within the healthcare system.
  • Vehicle Purchase Agreement Form: This legal document records the sale and purchase details of a vehicle, ensuring that all necessary information about the transaction, including the vehicle's condition, price, and warranties, is clearly defined. More details can be found at smarttemplates.net.
  • Follow-Up Care Instructions: After the examination, patients may receive a document detailing any recommended follow-up appointments, tests, or lifestyle changes. This ensures continuity of care.
  • Billing Information Form: This document provides details about payment methods and insurance coverage. It helps clarify financial responsibilities before or after the appointment.

Understanding these documents can enhance the annual physical examination experience. Each form plays a vital role in ensuring that healthcare providers have the necessary information to deliver optimal care. Being prepared with these documents can lead to a smoother, more efficient visit.

Common mistakes

Completing the Annual Physical Examination form is a crucial step in ensuring that your health is monitored effectively. However, many individuals make common mistakes that can lead to unnecessary complications or delays in care. Understanding these pitfalls can help you provide accurate information and streamline your medical visits.

One frequent error is leaving sections of the form blank. Each part of the form is designed to gather essential information about your health. Omitting details, such as your medical history or current medications, can result in follow-up visits that could have been avoided. Always take the time to fill out every section completely, even if you think some information may not be relevant.

Another mistake is failing to update your medication list. It is vital to include all medications you are currently taking, including over-the-counter drugs and supplements. If you have had any changes in your prescriptions since your last visit, be sure to note those as well. Inaccurate medication information can lead to potential drug interactions or inappropriate treatment recommendations.

People often forget to mention allergies or sensitivities. This information is crucial for your healthcare provider to avoid prescribing medications that could cause adverse reactions. If you have experienced any new allergies since your last appointment, make sure to include those on the form.

Additionally, many individuals overlook the importance of documenting past surgeries or hospitalizations. This section provides your healthcare provider with a comprehensive view of your medical history, which can influence current treatment decisions. Be thorough and include all relevant details, even if they seem minor.

Another common oversight is neglecting to indicate whether you take medications independently. This simple question can significantly impact how your healthcare team approaches your care. If you require assistance with your medications, it is essential to communicate that clearly.

When it comes to the immunization section, some people fail to provide accurate dates or forget to list all vaccinations received. Keeping this information updated is important for your health and helps prevent the spread of communicable diseases. If you have received any recent vaccinations, ensure they are recorded accurately.

Moreover, individuals sometimes do not specify if they have any communicable diseases. This can pose a risk not only to your health but also to others around you. If you are aware of any such conditions, it is imperative to disclose them and outline any precautions that need to be taken.

Lastly, many people neglect to review the additional comments section. This area allows you to share any specific concerns or updates regarding your health status. Taking a moment to reflect on any changes since your last visit can provide your healthcare provider with valuable insights and enhance the quality of your care.

By avoiding these common mistakes, you can help ensure that your Annual Physical Examination is as productive and informative as possible. Your health is paramount, and providing accurate information is a key step in taking charge of your well-being.

Sample - 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