ANNUAL PHYSICAL EXAMINATION FORM - Health & …
PHYSICAL EXAMINATION FORM
Name:
Address:
Sex:
Male
Female
DIAGNOSES/SIGNIFICANT HEALTH CONDITIONS
Date of Exam: Date of Birth:
CURRENT MEDICATIONS (Attach a second page if needed):
Medication Name
Dose Frequency
Diagnosis
Prescribing Physician Date Medication
Specialty
Prescribed
Allergies/Sensitivities:
IMMUNIZATIONS:
Tetanus/Diphtheria (every 10 years):
Flu Shot:
/
/
Other (specify)
/
/
OTHER MEDICAL/LAB/DIAGNOSTIC TESTS:
GYN exam w/PAP:
Date:
Results:
(women over age 18)
Mammogram:
Date:
Results:
(every 2 years- women ages 40-19, yearly for women 50 and over)
Prostate Exam:
Date:
Results:
(digital method-males 40 and over)
PSA
Date:
Results:
Other (specify)
Date:
Pneumonia Vaccine: Results:
/
/
Part Two: GENERAL PHYSICAL EXAMINATION
Blood Pressure:
/
Pulse:
Temp:
Height:
Weight:
BMI: ______
Vision Screening: Left _______ Right______ Corrected: yes
no
Hearing Screening: Pass
Refer
EVALUATION OF SYSTEMS
System Name Normal findings?
Eyes
Yes
No
Ears
Yes
No
Nose
Yes
No
Mouth/Throat
Yes
No
Head/Face/Neck
Yes
No
Lungs
Yes
No
Cardiovascular
Yes
No
Extremities
Yes
No
Abdomen
Yes
No
Gastrointestinal
Yes
No
Endocrine
Yes
No
Musculoskeletal
Yes
No
Integumentary
Yes
No
Lymphatic
Yes
No
Nervous System
Yes
No
Comments/Description
Name of physician (please print)
Physician's Signature
Date
Physician Address: ___________________________________________________________________ Physician Phone Number: ____________________________________
................
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