Fill in a Valid Annual Physical Examination Form

Annual Physical Examination - Usage Guidelines

Filling out the Annual Physical Examination form is a straightforward process that helps ensure your medical appointment goes smoothly. By providing accurate and complete information, you can avoid unnecessary delays or return visits. Here’s how to fill out the form step by step:

1. Part One: Pre-Appointment Information
   • Write your full name in the designated space.
   • Enter the date of your exam.
   • Fill in your address, including street, city, state, and ZIP code.
   • Provide your Social Security Number (SSN).
   • Input your date of birth.
   • Select your sex by checking the appropriate box (Male or Female).
   • List the name of the person accompanying you to the appointment.
   • Detail any significant health conditions or medical history in the space provided.
   • List any current medications, including name, dose, frequency, diagnosis, prescribing physician, and specialty prescribed. Attach an additional page if needed.
   • Indicate if you take medications independently by checking Yes or No.
   • Document any allergies or sensitivities.
   • List any contraindicated medications.
   • Fill in your immunization history, including dates and types of vaccines administered.
   • Complete the tuberculosis screening section with the date given, date read, and results.
   • Answer whether you are free of communicable diseases and list any precautions if not.
   • Document any additional medical, lab, or diagnostic tests performed.
   • List any hospitalizations or surgical procedures with dates and reasons.
2. Part Two: General Physical Examination
   • Record your blood pressure, pulse, respirations, temperature, height, and weight.
   • Evaluate each system by checking Yes or No for normal findings and providing comments as needed.
   • Complete the vision and hearing screening sections, indicating if further evaluation is recommended.
   • Write any additional comments regarding your medical history, medications, and recommendations for health maintenance.
   • Note any limitations or restrictions for activities and whether adaptive equipment is used.
   • Indicate if there has been a change in health status from the previous year.
   • Answer whether this individual is recommended for ICF/ID level of care and list any specialty consults recommended.
   • Provide details about any seizure disorders, including the type and date of the last seizure.
   • Print the name of the physician, obtain their signature, and include the date, address, and phone number.

After completing the form, review your answers to ensure accuracy. Bring the form to your appointment, as it will provide your healthcare provider with essential information to guide your examination and treatment plan. Being thorough now can lead to a more effective and efficient visit later!