Table of Contents
The Annual Physical Examination form serves as a crucial tool for both patients and healthcare providers, ensuring that all necessary health information is collected before a medical appointment. This comprehensive document requires individuals to fill out personal details such as their name, date of birth, and address, alongside vital medical history, including any significant health conditions and current medications. It also prompts patients to disclose allergies and past immunizations, which are essential for tailoring appropriate care. Furthermore, the form includes sections for various diagnostic tests and screenings, from blood pressure readings to specific evaluations like mammograms and prostate exams. By addressing these aspects, the form not only streamlines the examination process but also helps healthcare professionals provide informed and effective care. Completing this form accurately can significantly reduce the need for follow-up visits, making it a key component of preventative health measures.
Documents used along the form
When preparing for an annual physical examination, several other forms and documents may be required. These documents help provide a comprehensive view of an individual's health and ensure that the healthcare provider has all necessary information. Here are some commonly used forms:
- Medical History Form: This form collects detailed information about past medical issues, surgeries, and family health history. It helps the physician understand any potential risks or conditions that may affect the patient’s health.
- Consent for Treatment: Patients sign this document to give permission for medical examinations and treatments. It outlines the procedures and any associated risks, ensuring that patients are informed before consenting.
- Immunization Record: This document lists all vaccinations the patient has received. It is crucial for tracking immunization status and ensuring that the patient is up to date on required vaccines.
- Patient Information Sheet: This sheet gathers basic demographic information, such as contact details, insurance information, and emergency contacts. It ensures that the healthcare provider can reach the patient or family if necessary.
- Child Support Texas Form: The Exhibit: Child Support Order is essential for specifying the obligations of parents regarding child support payments. To understand and manage this process effectively, you can access the necessary documents here: https://txtemplate.com/child-support-texas-pdf-template.
- Medication List: Patients provide a list of current medications, including dosages and prescribing physicians. This helps prevent adverse drug interactions and ensures that the provider is aware of all medications being taken.
- Allergy Information Form: This document details any known allergies or sensitivities to medications, foods, or environmental factors. It is essential for avoiding allergic reactions during treatment.
- Lab Test Authorization: Patients may need to sign this form to allow the healthcare provider to perform specific laboratory tests. It ensures that patients are aware of which tests will be conducted.
- Referral Form: If a specialist consultation is needed, a referral form is used to direct the patient to the appropriate specialist. This ensures continuity of care and proper follow-up.
- Follow-Up Care Instructions: After the examination, patients receive instructions for follow-up care, including any recommended tests, treatments, or lifestyle changes. This document is vital for ongoing health management.
Having these forms ready can streamline the process of an annual physical examination. It ensures that both the patient and healthcare provider are well-informed and prepared for a thorough evaluation of health.
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Annual Physical Examination Example
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: ________________________ |
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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 |
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Specialty |
Prescribed |
Does the person take medications independently? |
Yes |
No |
Allergies/Sensitivities:_______________________________________________________________________________ |
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Contraindicated Medication: _________________________________________________________________________
IMMUNIZATIONS:
Tetanus/Diphtheria (every 10 years):______/_____/______ |
Type administered: _________________________ |
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Hepatitis B: #1 ____/_____/____ |
#2 _____/____/________ |
#3 _____/_____/______ |
Influenza (Flu):_____/_____/_____ |
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Pneumovax: _____/_____/_____ |
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Other: (specify)__________________________________________ |
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TUBERCULOSIS (TB) SCREENING: (every 2 years by Mantoux method; if positive initial chest |
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Date given __________ |
Date read___________ |
Results_____________________________________ |
Chest |
Results________________________________________________________ |
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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) |
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Mammogram: |
Date: _____________ |
Results: ________________________________________________ |
(every 2 years- women ages
Prostate Exam: |
Date: _____________ |
Results:______________________________________________________ |
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(digital |
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Hemoccult |
Date: _____________ |
Results:______________________________________________________ |
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Urinalysis |
Date:______________ |
Results: _________________________________________________ |
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CBC/Differential |
Date:______________ |
Results: ______________________________________________________ |
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Hepatitis B Screening |
Date:______________ |
Results: ______________________________________________________ |
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PSA |
Date:______________ |
Results: ______________________________________________________ |
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Other (specify)___________________________________________Date:______________ |
Results: ________________________________ |
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Other (specify)___________________________________________Date:______________ |
Results: ________________________________ |
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HOSPITALIZATIONS/SURGICAL PROCEDURES:
Date
Reason
Date
Reason
12/11/09, revised 7/24/12
PART TWO: GENERAL PHYSICAL EXAMINATION
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Please complete all information to avoid return visits. |
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Blood Pressure:______ /_______ Pulse:_________ |
Respirations:_________ Temp:_________ Height:_________ |
Weight:_________ |
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EVALUATION OF SYSTEMS |
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System Name |
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Normal Findings? |
Comments/Description |
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Eyes |
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Yes |
No |
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Ears |
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Yes |
No |
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Nose |
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Yes |
No |
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Mouth/Throat |
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Yes |
No |
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Head/Face/Neck |
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Yes |
No |
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Breasts |
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Yes |
No |
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Lungs |
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Yes |
No |
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Cardiovascular |
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Yes |
No |
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Extremities |
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Yes |
No |
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Abdomen |
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Yes |
No |
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Gastrointestinal |
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Yes |
No |
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Musculoskeletal |
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Yes |
No |
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Integumentary |
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Yes |
No |
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Renal/Urinary |
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Yes |
No |
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Reproductive |
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Yes |
No |
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Lymphatic |
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Yes |
No |
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Endocrine |
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Yes |
No |
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Nervous System |
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Yes |
No |
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VISION SCREENING |
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Yes |
No |
Is further evaluation recommended by specialist? |
Yes |
No |
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HEARING SCREENING |
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Yes |
No |
Is further evaluation recommended by specialist? |
Yes |
No |
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ADDITIONAL COMMENTS: |
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Medical history summary reviewed? |
Yes |
No |
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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)
___________________________________________________________________________________________________________ |
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Does this person use adaptive equipment? |
No |
Yes (specify):________________________________________________ |
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Change in health status from previous year? No |
Yes (specify):_________________________________________________ |
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This individual is recommended for ICF/ID level of care? (see attached explanation) Yes |
No |
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Specialty consults recommended? No |
Yes (specify):_________________________________________________________ |
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Seizure Disorder present? No Yes (specify type):__________________________________ Date of Last Seizure: ______________ |
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________________________________ |
_______________________________ |
_________________ |
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Name of Physician (please print) |
Physician’s Signature |
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Date |
Physician Address: _____________________________________________ |
Physician Phone Number: ____________________________ |
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12/11/09, revised 7/24/12
FAQ
What is the purpose of the Annual Physical Examination form?
The Annual Physical Examination form is designed to gather essential health information before your medical appointment. It helps healthcare providers assess your overall health, identify any significant medical conditions, and recommend necessary tests or treatments.
What information is required in Part One of the form?
Part One requires personal details such as your name, date of exam, address, Social Security Number, date of birth, and sex. You must also provide information about any significant health conditions, current medications, allergies, and immunizations. This section ensures that your healthcare provider has a comprehensive view of your health history.
How should I list my current medications?
List each medication by name, dosage, frequency, diagnosis, prescribing physician, and the date it was prescribed. If you take multiple medications, you may attach a second page. Indicate whether you take medications independently or need assistance.
What should I do if I have allergies or sensitivities?
Clearly list any allergies or sensitivities in the designated section of the form. This information is crucial for your healthcare provider to avoid prescribing medications that could cause adverse reactions.
How often should I update my immunization records?
Immunization records should be updated regularly. For example, the Tetanus/Diphtheria vaccine is required every 10 years, while the Influenza vaccine is recommended annually. Keep track of all immunizations and provide the dates administered on the form.
What if I have a history of communicable diseases?
If you have a history of communicable diseases, indicate this on the form. You should also list any specific precautions you take to prevent spreading the disease to others. This information is vital for ensuring the safety of both you and other patients.
What types of tests are included in the general physical examination?
The general physical examination includes evaluations of vital signs such as blood pressure, pulse, and temperature. It also assesses various body systems, including eyes, ears, lungs, and cardiovascular health. Results from any additional tests, like blood work or imaging, should also be documented.
How should I handle a change in health status?
If you experience a change in health status since your last visit, you must specify this on the form. This could include new symptoms, diagnoses, or treatments. Keeping your healthcare provider informed allows for better management of your health.
What recommendations might I receive after my examination?
After your examination, you may receive recommendations for health maintenance. This could include suggestions for lab work, therapies, exercise, dietary changes, and frequency of screenings. These recommendations aim to enhance your overall health and prevent future issues.
What happens if I need further evaluation by a specialist?
If your healthcare provider recommends further evaluation by a specialist, this will be noted on the form. Follow-up appointments may be necessary to address specific health concerns or conditions identified during your examination.
Key takeaways
Filling out the Annual Physical Examination form accurately is crucial for ensuring a smooth medical appointment. Here are key takeaways to keep in mind:
- Complete All Sections: Ensure that every section of the form is filled out thoroughly. Missing information can lead to delays or the need for additional visits.
- List Current Medications: Provide a detailed list of all medications, including dosages and prescribing physicians. This helps healthcare providers understand your treatment plan.
- Document Medical History: Include any significant health conditions and previous hospitalizations. A comprehensive medical history aids in accurate assessments and recommendations.
- Report Allergies: Clearly indicate any allergies or sensitivities. This information is vital for preventing adverse reactions during treatment.
- Follow Up on Recommendations: Pay attention to any recommendations made by the physician during the examination. This may include further tests or lifestyle changes for better health management.
Form Characteristics
| Fact Name | Description |
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| Purpose of the Form | The Annual Physical Examination form is designed to collect comprehensive health information to facilitate a thorough medical evaluation. |
| Required Information | Patients must provide personal details such as name, date of birth, address, and medical history to ensure accurate assessments. |
| Medication Disclosure | Current medications must be listed, including dosage and prescribing physician, to prevent adverse interactions during treatment. |
| Immunization Records | The form requires documentation of immunizations, which helps healthcare providers track vaccination history and needs. |
| Health Screenings | It includes sections for various health screenings, such as TB tests and cancer screenings, which are crucial for early detection. |
| State-Specific Regulations | In some states, specific laws govern the use of this form, including requirements for patient consent and privacy protections, such as HIPAA. |