Content Overview
Guide to Writing Annual Physical Examination
Completing the Annual Physical Examination form is an important step in ensuring that all necessary health information is accurately recorded before your medical appointment. This process helps healthcare providers understand your medical history and current health status. By following the steps below, you can fill out the form with ease and confidence.
- Begin with Part One. Fill in your Name, Date of Exam, and Address. Make sure to include your Social Security Number and Date of Birth.
- Select your Sex by checking the appropriate box for either Male or Female.
- Provide the Name of Accompanying Person, if applicable.
- List any Diagnoses/Significant Health Conditions. Include a summary of your medical history and any chronic health problems.
- Detail your Current Medications. For each medication, include the name, dose, frequency, diagnosis, prescribing physician, and the date prescribed. Attach an additional page if necessary.
- Indicate if you take medications independently by checking Yes or No.
- List any Allergies/Sensitivities and Contraindicated Medications.
- Fill out the Immunizations section, providing dates and types for Tetanus/Diphtheria, Hepatitis B, Influenza, Pneumovax, and any others.
- Complete the Tuberculosis (TB) Screening section, noting the date given, date read, and results. Include any chest x-ray details if necessary.
- In the Other Medical/Lab/Diagnostic Tests section, provide details for any relevant tests, including dates and results.
- Document any Hospitalizations/Surgical Procedures by providing the date and reason for each.
- Move to Part Two, where you will complete the General Physical Examination section. Record your Blood Pressure, Pulse, Respirations, Temperature, Height, and Weight.
- Evaluate each system listed in the Evaluation of Systems section. Mark Yes or No for normal findings and provide comments if needed.
- Complete the Vision Screening and Hearing Screening sections, indicating if further evaluation is recommended.
- Provide any Additional Comments, including medication changes, health maintenance recommendations, dietary instructions, and any limitations or restrictions.
- Indicate if there has been a change in health status from the previous year.
- Complete the physician’s information section, including the name, signature, date, address, and phone number.
Once the form is filled out, review it for accuracy. Ensure that all sections are completed to avoid any delays during your appointment. Bringing this comprehensive information will help your healthcare provider deliver the best possible care tailored to your needs.
Document Breakdown
| Fact Name | Description |
|---|---|
| Purpose of the Form | The Annual Physical Examination Form is designed to gather comprehensive health information before a medical appointment. This ensures that healthcare providers have the necessary details to offer the best care possible. |
| Required Information | Patients must complete all sections of the form, including personal details, medical history, current medications, and immunizations. Incomplete forms may lead to return visits, causing delays in care. |
| State-Specific Regulations | In states like California, the form adheres to the California Health and Safety Code, which mandates that healthcare providers maintain accurate patient records and obtain informed consent for treatment. |
| Immunization Records | The form includes a section for immunization history, detailing vaccines received and their dates. This is crucial for assessing a patient's immunity and identifying any necessary vaccinations. |
| Evaluation of Systems | Part two of the form requires a general physical examination, where various body systems are evaluated. This section helps identify any abnormalities and informs the physician's recommendations for further care. |
FAQ
What is the purpose of the Annual Physical Examination form?
The Annual Physical Examination form is designed to collect important health information from individuals prior to their medical appointments. This information helps healthcare providers understand a patient's medical history, current medications, and any significant health conditions. Completing the form accurately can help streamline the examination process and ensure that all necessary evaluations are conducted.
What information is required in Part One of the form?
Part One requires personal details such as the individual's name, date of birth, and address. It also asks for the Social Security Number and the name of an accompanying person. Additionally, patients must provide a summary of their medical history, current medications, allergies, and vaccination records. This section is crucial for the healthcare provider to assess the patient's overall health and any potential risks.
Why is it important to list current medications?
Listing current medications is vital for several reasons. It allows healthcare providers to avoid potential drug interactions and ensure that any prescribed treatments do not conflict with existing medications. Furthermore, knowing the dosage and frequency helps in assessing the effectiveness of the current treatment plan and making necessary adjustments.
What should I do if I have allergies or sensitivities?
If you have allergies or sensitivities, it is essential to list them clearly on the form. This information helps healthcare providers take necessary precautions during examinations and treatments. Being aware of allergies can prevent adverse reactions to medications or procedures.
How often should immunizations be updated?
Immunizations should be updated according to recommended schedules. For example, a Tetanus/Diphtheria vaccine is typically administered every ten years. Other vaccines, such as the flu vaccine, may be recommended annually. It is important to keep vaccination records current to ensure optimal protection against preventable diseases.
What tests are included in the general physical examination?
The general physical examination includes a variety of tests and evaluations. These may involve checking vital signs like blood pressure and pulse, as well as assessments of different body systems, such as eyes, ears, and cardiovascular health. Specific tests, such as a GYN exam, mammogram, or prostate exam, may also be included based on age and gender guidelines.
What should I do if there are changes in my health status?
If there have been changes in your health status since the last examination, it is crucial to indicate this on the form. Providing this information allows healthcare providers to tailor their assessments and recommendations to your current condition, ensuring that any new health issues are addressed appropriately.
What happens if I do not complete the form accurately?
Failing to complete the form accurately may result in the need for additional visits or delays in receiving appropriate care. Incomplete information can hinder the healthcare provider's ability to make informed decisions regarding diagnosis and treatment. It is advisable to review the form thoroughly before submission to minimize the risk of errors.
How can I ensure my privacy when filling out this form?
To ensure privacy when filling out the Annual Physical Examination form, it is best to complete it in a secure and private setting. Additionally, sharing the form only with authorized healthcare personnel will help protect your personal information. Most healthcare facilities have policies in place to safeguard patient data and maintain confidentiality.
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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
