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.
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Misconceptions about the Annual Physical Examination form can lead to confusion and missed opportunities for important health assessments. Here are nine common misconceptions clarified:
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.
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.
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.
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:
Results:______________________________________________________
(digital method-males 40 and over)
Hemoccult
Urinalysis
Date:______________
Results: _________________________________________________
CBC/Differential
Results: ______________________________________________________
Hepatitis B Screening
PSA
Other (specify)___________________________________________Date:______________
Results: ________________________________
HOSPITALIZATIONS/SURGICAL PROCEDURES:
Date
Reason
12/11/09, revised 7/24/12
PART TWO: GENERAL PHYSICAL EXAMINATION
Blood Pressure:______ /_______ Pulse:_________
Respirations:_________ Temp:_________ Height:_________
Weight:_________
EVALUATION OF SYSTEMS
System Name
Normal Findings?
Comments/Description
Eyes
Ears
Nose
Mouth/Throat
Head/Face/Neck
Breasts
Lungs
Cardiovascular
Extremities
Abdomen
Gastrointestinal
Musculoskeletal
Integumentary
Renal/Urinary
Reproductive
Lymphatic
Endocrine
Nervous System
VISION SCREENING
Is further evaluation recommended by specialist?
HEARING SCREENING
ADDITIONAL COMMENTS:
Medical history summary reviewed?
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?
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
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
Physician Address: _____________________________________________
Physician Phone Number: ____________________________
Da Form 2166-9-1a - Incorporate the form into annual performance evaluations as per AR 623-3 guidelines.
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