Free Annual Physical Examination PDF Form

The Annual Physical Examination form is a crucial document that helps healthcare providers gather essential information about a patient’s health. This form ensures that all relevant medical history, medications, and health conditions are documented prior to the appointment. By completing this form accurately, patients can help facilitate a more effective and comprehensive medical evaluation.

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The Annual Physical Examination form is an essential tool designed to ensure that individuals receive comprehensive healthcare. Completing this form accurately helps avoid unnecessary return visits and streamlines the examination process. It begins with basic personal information, such as name, date of birth, and address, which are vital for identifying the patient. The form also includes sections for medical history, current medications, and any allergies or sensitivities. This information is crucial for healthcare providers to understand existing health conditions and tailor their approach accordingly. Immunization records, including vaccinations like Tetanus and Influenza, are documented to keep track of preventive care. Additionally, the form contains sections for tuberculosis screening and various medical tests, ensuring that all relevant health aspects are evaluated. The general physical examination part records vital signs and evaluates different body systems, noting any abnormalities. Overall, this form is a comprehensive guide that promotes proactive health management and facilitates communication between patients and healthcare providers.

Annual Physical Examination 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

Documents used along the form

The Annual Physical Examination form is an important document used to gather comprehensive health information before a medical appointment. Along with this form, several other documents may be required to ensure that all necessary health details are captured accurately. Below are four common forms and documents that are often used in conjunction with the Annual Physical Examination form.

Medical History Form: This document collects detailed information about a patient's past medical history, including previous illnesses, surgeries, and family health history. It helps healthcare providers understand any underlying conditions that may affect current health.
Articles of Incorporation: This crucial document formally establishes a corporation’s existence under Colorado state law and contains essential information about the company. For more information, visit coloradoforms.com/.
Medication List: Patients should provide a list of all medications they are currently taking, including prescription drugs, over-the-counter medications, and supplements. This list is crucial for avoiding potential drug interactions and ensuring safe treatment.
Immunization Record: This form details all vaccinations a patient has received, including dates and types of immunizations. It is essential for tracking vaccine status and ensuring compliance with public health recommendations.
Consent for Treatment: Patients typically sign this document to give healthcare providers permission to perform examinations, tests, and treatments. It ensures that patients are informed about the procedures they will undergo during their visit.

These documents, when used alongside the Annual Physical Examination form, provide a comprehensive view of a patient's health and medical history. Together, they facilitate better communication between patients and healthcare providers, leading to more effective care.

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Key takeaways

Here are key takeaways for filling out and using the Annual Physical Examination form:

Complete all sections: Ensure every part of the form is filled out to prevent delays or the need for return visits.
Provide accurate medical history: Include a summary of past diagnoses and chronic health problems for a comprehensive evaluation.
List current medications: Detail all medications, including dosages and prescribing physicians. Attach an additional page if necessary.
Document immunizations: Record dates and types of immunizations received, as this information is crucial for your health records.
Be honest about health conditions: Disclose any communicable diseases and follow recommended precautions to protect others.
Review evaluation of systems: Confirm whether each system is normal and provide comments where necessary to assist your healthcare provider.
Update changes in health status: Note any significant changes since the last examination, as this information can impact your care.

Form Overview

Fact Name	Description
Purpose	The Annual Physical Examination form collects essential health information for preventive care.
Completion Requirement	All sections must be filled out to avoid unnecessary return visits.
Personal Information	Includes name, date of exam, address, date of birth, and social security number.
Medical History	Patients should list significant health conditions and current medications.
Immunization Records	Details on immunizations, including dates and types, must be provided.
Screening Tests	Includes tuberculosis screening and various diagnostic tests based on gender and age.
Vital Signs	Blood pressure, pulse, respirations, temperature, height, and weight are recorded during the exam.
Evaluation of Systems	Physicians assess multiple body systems, noting normal findings or concerns.
Special Recommendations	Includes recommendations for health maintenance, dietary changes, and activity limitations.
State-Specific Laws	In some states, specific forms and regulations govern the use of physical examination forms; consult local laws.

Frequently Asked Questions

What is the purpose of the Annual Physical Examination form?

The Annual Physical Examination form is designed to gather essential health information about an individual before their medical appointment. It helps healthcare providers assess the patient's medical history, current medications, allergies, and any significant health conditions. This information is crucial for ensuring a thorough and effective examination.

What information do I need to provide in Part One of the form?

In Part One, you need to complete personal details such as your name, date of birth, and address. Additionally, you should list any significant health conditions, current medications, allergies, and immunizations. This section may also require information about any hospitalizations or surgical procedures you have undergone.

How should I document my current medications?

You should list each medication by its name, dosage, frequency of intake, and the diagnosis for which it was prescribed. If you have multiple medications, you may attach a second page to ensure all information is captured. Indicate whether you take medications independently and note any allergies or sensitivities.

What immunizations should I include on the form?

Be sure to include details about your immunizations, such as Tetanus/Diphtheria, Hepatitis B, Influenza, and Pneumovax. For each immunization, provide the date administered and the type given. If you have received any other vaccinations, specify those as well.

What does the tuberculosis (TB) screening section entail?

This section requires you to document the date the TB test was given, the date it was read, and the results. If the initial test is positive, a chest x-ray should be noted along with its date and results. Indicate if you are free of communicable diseases and list any precautions necessary to prevent spreading illness.

What should I expect in Part Two of the form?

Part Two focuses on the general physical examination. You will need to provide vital signs such as blood pressure, pulse, and temperature. Additionally, you will evaluate various systems in your body, indicating whether findings are normal or if there are any comments to add. This section helps the healthcare provider understand your overall health status.

How can I document any changes in my health status?

There is a specific section in the form where you can indicate any changes in your health status compared to the previous year. If there are changes, specify what they are. This helps your healthcare provider tailor their approach to your current needs.

What should I do if I have questions about filling out the form?

If you have questions or need assistance while completing the form, do not hesitate to reach out to your healthcare provider's office. They can provide guidance and ensure that you fill out the form accurately, which will help facilitate a smoother appointment.

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Misconceptions

Misconceptions surrounding the Annual Physical Examination form can lead to confusion and missed opportunities for care. Here are ten common misconceptions, along with clarifications to help individuals better understand the purpose and requirements of this important document.

It is optional to complete the form. Many believe that filling out the Annual Physical Examination form is not necessary. However, providing complete and accurate information is crucial for effective medical evaluation.
Only new patients need to fill out the form. Some think that only first-time visitors need to complete the form. In reality, all patients should fill it out annually to keep their medical records updated.
All sections of the form must be filled out in detail. While thoroughness is appreciated, patients are encouraged to provide as much information as they can. If certain sections are not applicable, it is acceptable to leave them blank.
The form is only for adults. This misconception overlooks that children also require annual physical examinations. Parents or guardians should complete the form for minors.
Medications do not need to be listed if they are over-the-counter. It is important to include all medications, including over-the-counter drugs, as they may interact with prescribed medications.
Immunization history is not important. Some individuals may think that their immunization history is irrelevant. However, it is essential for healthcare providers to know this information to assess overall health and recommend necessary vaccinations.
The form only addresses physical health. In addition to physical health, the form also considers mental and emotional well-being, allowing for a more comprehensive evaluation.
Only one person can accompany the patient to the appointment. While the form asks for the name of an accompanying person, more than one individual may attend the appointment for support.
Completing the form takes a lot of time. Many believe that filling out the form is a lengthy process. In fact, most sections can be completed relatively quickly, especially with prior preparation.
The form is not reviewed by the physician. Some patients may think that the information provided is overlooked. However, healthcare providers review the form carefully to ensure that they can offer the best possible care.

Understanding these misconceptions can help individuals approach their annual physical examination with confidence and clarity. Completing the form accurately and thoroughly is a vital step in maintaining health and wellness.