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Misconceptions

Understanding the Annual Physical Examination form is crucial for ensuring a smooth medical experience. Here are seven common misconceptions that people often have:

  • It's just a formality. Many believe that completing this form is merely a formality. In reality, accurate information is essential for your healthcare provider to assess your health effectively and provide appropriate care.
  • Only new patients need to fill it out. Some think that only first-time patients need to complete the form. However, even returning patients should update their information regularly to reflect any changes in their health status or medications.
  • All sections must be filled out. While it's important to provide as much information as possible, not every section may apply to you. If you don't have certain information, it's acceptable to leave those sections blank.
  • My doctor already knows my medical history. Many assume that their doctor remembers all details about their medical history. However, providing a summary ensures that nothing important is overlooked, especially if multiple healthcare providers are involved.
  • Medications don’t need to be listed if they are unchanged. Some believe they can skip listing medications if they haven't changed. It's crucial to list all medications, including those that remain the same, to avoid potential interactions and ensure comprehensive care.
  • Immunizations are optional. People often think immunizations are optional or not necessary. In fact, staying up-to-date with immunizations is vital for your health and the health of those around you.
  • Only physical health matters. Many focus solely on physical health when completing the form. Mental and emotional health are equally important and should be addressed in the comments section if relevant.

Addressing these misconceptions can lead to better health outcomes and a more efficient healthcare experience. Be proactive and thorough when filling out your Annual Physical Examination form.

Detailed Steps for Filling Out Annual Physical Examination

Filling out the Annual Physical Examination form is a straightforward process that requires attention to detail. Each section of the form is designed to collect essential health information that will assist healthcare providers in delivering the best possible care. Following the steps outlined below will help ensure that all necessary information is accurately recorded, minimizing the need for return visits.

  1. Begin with PART ONE. Fill in your Name, Date of Exam, Address, Social Security Number (SSN), Date of Birth, and Sex (check the appropriate box).
  2. Provide the Name of Accompanying Person, if applicable.
  3. List any Diagnoses/Significant Health Conditions you have. Include a brief medical history and any chronic health problems.
  4. In the Current Medications section, list each medication's name, dose, frequency, diagnosis, prescribing physician, and date prescribed. If you need more space, attach an additional page.
  5. Indicate whether you take medications independently by checking Yes or No.
  6. Document any Allergies/Sensitivities you have and any Contraindicated Medication.
  7. Complete the Immunizations section by filling in the dates and types of vaccines received.
  8. For the Tuberculosis (TB) Screening, provide the date given, date read, and results. Note if a chest x-ray was done and its results.
  9. Answer whether you are free of communicable diseases by checking Yes or No. If not, list precautions.
  10. In the Other Medical/Lab/Diagnostic Tests section, fill in the dates and results for any tests you have undergone.
  11. Document any Hospitalizations/Surgical Procedures by noting the date and reason for each.
  1. Move to PART TWO. Record your Blood Pressure, Pulse, Respirations, Temperature, Height, and Weight.
  2. For the Evaluation of Systems, indicate if normal findings were present for each system by checking Yes or No. Include any comments or descriptions as needed.
  3. Complete the Vision Screening and Hearing Screening sections, noting if further evaluation is recommended.
  4. Provide any Additional Comments regarding your medical history, medications, health maintenance recommendations, and any limitations or restrictions for activities.
  5. Indicate if you use adaptive equipment and if there has been a change in health status from the previous year.
  6. Finally, answer whether you are recommended for ICF/ID level of care and if any specialty consults are recommended.
  7. Sign the form by printing your name, signing, and dating it. Include your physician's address and phone number.

After completing the form, review it for any missing information. Ensure that all sections are filled out accurately. Once verified, submit the form to your healthcare provider before your scheduled appointment.

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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

Dos and Don'ts

When filling out your Annual Physical Examination form, there are several important dos and don’ts to keep in mind. This will help ensure that your visit goes smoothly and all necessary information is accurately conveyed.

  • Do complete all sections of the form to avoid delays in your appointment.
  • Do provide accurate and up-to-date medical history, including any chronic health conditions.
  • Do list all current medications, including dosage and frequency, even if they seem minor.
  • Do mention any allergies or sensitivities clearly to prevent adverse reactions.
  • Do ensure your contact information is correct, so you can be reached if necessary.
  • Don’t leave any sections blank, as this could lead to a need for follow-up visits.
  • Don’t exaggerate or downplay your symptoms or health conditions; honesty is crucial.
  • Don’t forget to sign and date the form, as this validates the information provided.
  • Don’t assume that your doctor remembers your entire medical history; provide it each time.

By following these guidelines, you can help ensure that your Annual Physical Examination is as effective and efficient as possible.

Key takeaways

Filling out the Annual Physical Examination form can seem daunting, but it’s essential for ensuring a smooth and efficient medical appointment. Here are some key takeaways to keep in mind:

  • Complete All Sections: Ensure that every section of the form is filled out completely. Missing information can lead to delays and additional visits.
  • Accurate Medical History: Provide a thorough summary of your medical history, including chronic health problems. This helps your healthcare provider understand your health better.
  • List Current Medications: Include all medications you are currently taking, along with dosages and prescribing physicians. If needed, attach an additional page.
  • Be Honest About Allergies: Clearly state any allergies or sensitivities you have. This information is crucial for avoiding adverse reactions during treatment.
  • Immunization Records: Update your immunization history accurately. Keeping this information current helps your provider assess your vaccination needs.
  • Communicable Diseases: Indicate whether you are free of communicable diseases. If not, provide specific precautions to prevent spreading illness.
  • Follow-Up Tests: Document any recent medical tests and their results. This ensures your doctor has all relevant information at hand.
  • Physical Examination Details: Fill in your vital signs and any observations regarding your health. This includes blood pressure, pulse, and any symptoms you may be experiencing.
  • Recommendations and Limitations: Note any recommendations for health maintenance, as well as any limitations on activities. This helps tailor your care plan effectively.

By keeping these points in mind, you can help ensure that your Annual Physical Examination goes smoothly, allowing for a more productive visit with your healthcare provider.

Similar forms

The Annual Physical Examination form shares similarities with the Medical History Form. Both documents collect essential personal information, including the patient's name, date of birth, and contact details. They also require a summary of the patient's medical history, which can include previous diagnoses, surgeries, and chronic conditions. This information helps healthcare providers understand the patient's background and make informed decisions about their care.

Another document that aligns closely with the Annual Physical Examination form is the Immunization Record. This record specifically tracks vaccinations received by the patient, including dates and types of immunizations. Like the physical examination form, it emphasizes the importance of maintaining up-to-date immunizations for overall health. Both documents can serve as vital references for healthcare providers when assessing a patient's health status and potential risks.

The Patient Intake Form is also similar in purpose and structure. It is typically completed before a medical appointment and gathers comprehensive information about the patient's current health status, medications, and allergies. Both forms aim to provide a thorough overview of the patient’s health, ensuring that healthcare providers have the necessary information to deliver appropriate care during the visit.

The Consent for Treatment form shares a functional relationship with the Annual Physical Examination form. While the latter assesses health, the consent form ensures that the patient agrees to the proposed medical procedures and examinations. Both documents are essential for establishing a clear understanding between the patient and healthcare provider, fostering a transparent and respectful healthcare environment.

The Follow-Up Care Plan is another document that mirrors the Annual Physical Examination form in its intent to monitor a patient’s health over time. It outlines recommendations for ongoing care, including follow-up appointments, lifestyle changes, and additional tests. Similar to the physical examination form, it aims to ensure that patients receive the necessary support to maintain or improve their health after their initial evaluation.

Lastly, the Laboratory Test Requisition form is akin to the Annual Physical Examination form in that it often accompanies a physical exam. This document requests specific lab tests based on the findings of the examination. Both forms play a crucial role in the diagnostic process, allowing healthcare providers to gather more detailed information about the patient's health and tailor their treatment plans accordingly.

Documents used along the form

The Annual Physical Examination form is an essential document that helps healthcare providers assess a patient's overall health. Alongside this form, there are several other documents that can enhance the examination process and provide a comprehensive view of a patient's health history. Here are five commonly used forms that often accompany the Annual Physical Examination form.

  • Medical History Questionnaire: This document gathers detailed information about a patient's past medical conditions, surgeries, and family health history. It helps physicians understand risk factors and tailor their recommendations.
  • Consent for Treatment Form: This form ensures that patients understand and agree to the procedures and treatments they will receive during their medical appointment. It protects both the patient and the provider by clarifying expectations.
  • Immunization Record: This record lists all vaccinations a patient has received. It is crucial for tracking immunization history and ensuring that patients are up to date with necessary vaccines.
  • Lab Test Requisition Form: This form is used to request specific laboratory tests. It includes details such as the type of tests needed and the patient's information, ensuring accurate and efficient processing of lab work.
  • Referral Form: When a patient needs to see a specialist, a referral form is completed. This document provides the specialist with relevant patient information and the reason for the referral, facilitating better continuity of care.

These forms work together with the Annual Physical Examination form to create a thorough and effective healthcare experience. They ensure that healthcare providers have all the necessary information to make informed decisions about a patient's care.