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Fill in a Valid Annual Physical Examination Form

The Annual Physical Examination form is a comprehensive document designed to gather essential health information prior to a medical appointment. It includes personal details, medical history, and current medications, ensuring that healthcare providers have the necessary information to offer the best care. Completing this form accurately helps prevent the need for additional visits and promotes a thorough understanding of your health status.

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Example - 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

Documents used along the form

The Annual Physical Examination form is a crucial document for assessing an individual's health status. Alongside this form, several other documents are often used to ensure a comprehensive evaluation of a person's medical history and current health conditions. Below is a list of additional forms and documents that may accompany the Annual Physical Examination form, each serving a specific purpose in the healthcare process.

Medical History Form: This document collects detailed information about a patient's past medical conditions, surgeries, and family health history. It helps healthcare providers understand risk factors and tailor care accordingly.
Medication List: A comprehensive list of all medications a patient is currently taking, including prescriptions, over-the-counter drugs, and supplements. This list is essential for preventing drug interactions and ensuring safe prescribing practices.
Immunization Record: This form outlines a patient’s vaccination history. It is important for tracking immunizations received and determining if any are due, particularly for children and adults at higher risk.
Lab Test Results: These documents provide the outcomes of various laboratory tests, such as blood work or urinalysis. They offer valuable insights into a patient's health and help in diagnosing potential issues.
Referral Form: When a primary care provider refers a patient to a specialist, this form is used to convey relevant medical information and the reason for the referral. It ensures continuity of care and proper follow-up.
NYCHA Annual Recertification Form: This document is essential for confirming compliance with rent stabilization laws and ensuring proper notification regarding lease renewals. Completing the form accurately supports housing stability and adherence to federal regulations. For more details, visit https://nytemplates.com/blank-nycha-annual-recertification-template/.
Consent Forms: These documents obtain a patient’s permission for specific medical procedures or treatments. They are crucial for ensuring that patients are informed about the risks and benefits of their care.
Health Risk Assessment: This form evaluates a patient's lifestyle choices and health behaviors, such as smoking, diet, and exercise. It helps identify areas for improvement and guides health promotion strategies.
Advance Directive: This legal document outlines a patient’s preferences for medical treatment in the event they are unable to communicate their wishes. It is essential for ensuring that healthcare providers respect a patient's choices regarding end-of-life care.
Follow-Up Appointment Schedule: This document outlines the recommended follow-up visits or tests needed after the annual examination. It helps patients stay on track with their healthcare needs.

These documents collectively contribute to a thorough understanding of a patient’s health and ensure that healthcare providers can offer informed and effective care. By utilizing these forms alongside the Annual Physical Examination form, medical professionals can better assess and manage a patient's health over time.