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The Annual Physical Examination form serves as a crucial tool for both patients and healthcare providers, ensuring a comprehensive overview of an individual's health status. This form is divided into two main parts, each designed to gather essential information that will facilitate a thorough medical evaluation. In the first part, patients are required to provide personal details such as their name, date of birth, and address, along with a summary of their medical history, current medications, and any allergies or sensitivities. This section also includes vital information about immunizations, tuberculosis screening, and any past hospitalizations or surgical procedures. The second part focuses on the general physical examination, where healthcare professionals will document vital signs, assess various body systems, and note any abnormalities. Additionally, there is space for recommendations regarding health maintenance, dietary guidelines, and potential limitations on activities. By completing this form accurately and thoroughly, patients help ensure that their healthcare providers have the necessary information to deliver the best possible care.

Similar forms

The Annual Health Assessment form is similar to the Patient Intake Form. Both documents gather essential information about the patient's medical history and current health status. They typically require personal details such as name, date of birth, and contact information. The Patient Intake Form also includes sections for current medications and allergies, which align closely with the Annual Physical Examination form's requirements for medication and allergy information.

Another comparable document is the Medical History Questionnaire. This form focuses on the patient’s past medical conditions and family history. Like the Annual Physical Examination form, it seeks to identify significant health issues and chronic conditions. Both documents aim to provide healthcare providers with a comprehensive view of the patient’s health to facilitate informed decision-making during medical evaluations.

The Immunization Record is another document that shares similarities with the Annual Physical Examination form. Both forms track vaccination history, ensuring that patients receive necessary immunizations. The Annual Physical Examination form specifically lists required immunizations, while the Immunization Record provides a detailed history of all vaccinations administered, including dates and types of vaccines.

The Lab Test Requisition Form also bears resemblance to the Annual Physical Examination form. Both documents may include sections for ordering specific tests and recording results. The Annual Physical Examination form outlines various tests that may be recommended during the examination, while the Lab Test Requisition Form focuses specifically on laboratory tests that need to be conducted.

The Health Risk Assessment form aligns closely with the Annual Physical Examination form in its purpose to evaluate a patient’s overall health. Both documents assess lifestyle factors, medical history, and current health status. The Health Risk Assessment often includes questions about diet, exercise, and personal habits, similar to the health maintenance recommendations found in the Annual Physical Examination form.

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The Medication Reconciliation Form is another document that shares a purpose with the Annual Physical Examination form. Both forms aim to ensure that healthcare providers have an accurate list of the patient’s medications. The Annual Physical Examination form includes a section for current medications, while the Medication Reconciliation Form specifically addresses any changes in medications, dosages, or new prescriptions.

The Consent for Treatment form is also similar to the Annual Physical Examination form in that it is often completed prior to a medical appointment. Both documents require patient information and aim to ensure that patients understand the procedures they are consenting to. The Consent for Treatment form specifically addresses patient agreement to medical care, while the Annual Physical Examination form focuses on gathering necessary health information.

The Follow-Up Care Plan is another document that resembles the Annual Physical Examination form. Both forms outline recommendations for ongoing health management after an examination. The Follow-Up Care Plan typically includes specific instructions for further testing or treatment, similar to the recommendations provided in the Annual Physical Examination form.

Lastly, the Emergency Contact Form shares similarities with the Annual Physical Examination form. Both documents require personal information and may include details about the patient’s health status. The Emergency Contact Form focuses on who should be contacted in case of an emergency, while the Annual Physical Examination form emphasizes the patient's health history and current conditions that may be relevant in an emergency situation.

Form Specifications

Fact Name Details
Purpose The Annual Physical Examination form is designed to gather essential health information prior to a medical appointment.
Required Information Patients must complete all sections, including personal details, medical history, and current medications, to avoid delays.
Immunization Records Patients are required to provide information on immunizations, including dates and types administered, to ensure comprehensive care.
Health Screenings Various health screenings, such as TB tests and cancer screenings, are included to assess the patient's overall health status.
Medication Management Patients must list current medications, including dosages and prescribing physicians, to facilitate accurate treatment planning.
Legal Compliance In many states, the form must comply with healthcare regulations, such as HIPAA, to protect patient privacy.
Emergency Information The form includes a section for critical information pertinent to diagnosis and treatment in case of an emergency.
Physician’s Verification At the end of the form, the physician must sign and date it, confirming the information provided during the examination.

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