Add or replace text, adjust formatting, insert legally binding eSignatures, and send documents for signing without hopping between apps.
PA Annual Physical Examination Form 2012-2025 free printable template
Show details
ANNUAL PHYSICAL EXAMINATION FORM Please complete all information to avoid return visits. Part One TO BE COMPLETED PRIOR TO MEDICAL APPOINTMENT Name Address Date of Exam SSN Date of Birth Name of Accompanying Person Sex Male Female 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 Specialty Date Medication...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 // 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 women over age 18 Mammogram every 2 years- women ages 40-49 yearly for women 50 and over Prostate Exam digital method-males 40 and over Hemoccult Urinalysis CBC/Differential Hepatitis B Screening PSA HOSPITALIZATIONS/SURGICAL PROCEDURES Date 12/11/09 revised 7/24/12 Reason Part Two GENERAL PHYSICAL EXAMINATION Blood Pressure / Pulse Respirations Temp Height Weight EVALUATION OF SYSTEMS System Name Normal...Findings Eyes Ears Nose Mouth/Throat Head/Face/Neck Breasts Lungs Cardiovascular Extremities Abdomen Gastrointestinal Musculoskeletal Integumentary Renal/Urinary Reproductive Lymphatic Endocrine Nervous System VISION SCREENING HEARING SCREENING Comments/Description Is further evaluation recommended by specialist Yes Additional Comments Medical history summary reviewed Yes 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. 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 This individual is recommended for ICF/ID level of care see attached explanation Yes Specialty...consults recommended No Seizure Disorder present No Yes specify type Date of Last Seizure Name of Physician please print Physician s Signature Physician Address Physician Phone Number.
pdfFiller is not affiliated with any government organization
Fill out, sign, and share forms from a single PDF platform
Manage all your documents quickly and securely in the cloud.
Edit and sign in one place
Create professional forms
Add and customize fillable fields to tailor each form to your needs and ensure easy completion without printing and scanning.
Simplify data collection
Quickly share forms via email or a secure link, enabling anyone to complete forms online in seconds, on any device.
Manage forms centrally
Keep all your forms and templates organized in one secure, cloud-based platform, track changes easily, and export documents in any format.
Why pdfFiller is the best tool for your documents and forms
End-to-end document management
From editing and signing to collaboration and tracking, pdfFiller has everything you need to get your documents done quickly and efficiently.
Accessible from anywhere
pdfFiller is fully cloud-based. This means you can edit, sign, and share documents from anywhere using your computer, smartphone, or tablet.
Secure and compliant
pdfFiller lets you securely manage documents following global laws like ESIGN, CCPA, and GDPR. It's also HIPAA and SOC 2 compliant.
Complete Guide to the Annual Physical Examination Form on pdfFiller
Filling out an annual physical examination form is essential for tracking your health over time. With pdfFiller, the process becomes seamless, ensuring you provide all the necessary information accurately.
Understanding the Importance of the Annual Physical Examination
Annual physical exams play a crucial role in maintaining your overall health. They not only provide a comprehensive overview of your current health status but also enable early detection of potential issues.
-
Annual physical exams are crucial for health maintenance, allowing for early disease detection.
-
Statistics show that regular check-ups significantly reduce the risk of chronic diseases.
What are the key sections of the annual physical examination form?
The annual physical examination form consists of several vital sections that ensure thorough evaluation. Understanding these sections can facilitate accurate completion.
Vital personal information
The first section captures essential details about the patient.
-
Name, Address, Date of Exam, SSN, and Date of Birth are required.
-
Details about the accompanying person, including their relation, must also be included.
Medical history overview
A concise overview of significant health conditions helps prevent unnecessary repeat visits.
-
Note any chronic issues to assist the healthcare provider in understanding your health background.
-
Including a medical history summary can improve the evaluation process.
Current medications and allergies
It’s vital to disclose current medications, their dosages, and the prescribing physicians.
-
List all medications, including any over-the-counter drugs.
-
Disclose any known allergies to prevent health risks during treatment.
Immunization records
Proper documentation of vaccinations is necessary for ongoing health monitoring.
-
Provide details of necessary vaccinations and their validity periods.
-
The healthcare provider will assess if additional vaccinations are needed.
Screening and diagnostic tests
Standard tests vary based on age and gender.
-
Include screening tests like TB screening and GYN exams.
-
Specific tests may be required for different gender and age brackets.
Hospitalizations and surgical history
Detailing your hospitalizations and surgical history aids in a thorough health evaluation.
-
Include any previous hospitalizations or surgeries.
-
This information is critical for understanding any potential health risks.
General physical examination details
This section covers the recording of vital signs.
-
Document vital signs: blood pressure, pulse, temperature, height, and weight.
-
Summarize the systems evaluation to assess overall health effectively.
How to fill out the annual physical examination form on pdfFiller
Filling out the form online has never been easier. Follow these steps to ensure you complete it accurately.
-
Navigate to pdfFiller’s platform to access the form.
-
Use the editing tools to input your information directly.
-
Utilize eSigning features to ensure your form is signed electronically.
Managing your health records with pdfFiller
Once your form is filled out, managing it becomes seamless through pdfFiller's capabilities.
-
Store and access your documents anytime from anywhere.
-
Enjoy a centralized document management system for all your health records.
Compliance and updating essential information
Keeping your health records updated is crucial. Regular updates ensure compliance and accuracy.
-
Adhere to guidelines for keeping your records compliant.
-
Update your information after any significant health changes.
Frequently Asked Questions about physical form templates
What is an annual physical examination form?
The annual physical examination form is a document that collects crucial information about a patient's health. It assists healthcare providers in conducting a comprehensive evaluation during yearly check-ups.
Why is it important to fill out this form accurately?
Accurate completion of the form is vital as it directly affects the quality of care you receive. Incomplete or incorrect details can lead to misdiagnosis or ineffective treatment.
Can I update my health records after filling out the form?
Yes, you can and should update your records if any significant health changes occur. Maintaining current information ensures better healthcare and compliance with records management guidelines.
How does pdfFiller help with filling out forms?
pdfFiller provides tools for easy editing, eSigning, and secure management of forms. Its online platform allows for straightforward form completion, ensuring a stress-free experience.
What sections are typically included in the form?
The essential sections typically include personal information, medical history, current medications, immunization records, and general details of the physical examination. Each section captures key aspects for an accurate health assessment.
pdfFiller scores top ratings on review platforms
I HAD NOT FOUND ONE THAT WOULD WORK SO…
I HAD NOT FOUND ONE THAT WOULD WORK SO WELL
Great!
Very easy to use. It really helped!
People Also Ask about physical form for work
What are the 6 components of a physical exam?
The components of a physical exam include: Inspection. Your examiner will look at, or "inspect" specific areas of your body for normal color, shape and consistency. Palpation. Percussion. Auscultation. The Neurologic Examination:
What is included in a preventive physical exam?
Preventive Visit: Annual Checkups Focused on Living Well Complete physical exam. Blood pressure, blood glucose and cholesterol screening tests. Pelvic exams, pap smear. Prostate and colorectal cancer screenings. Sexually-transmitted disease testing. A thorough review of your general health and well-being.
What is a full physical exam?
A comprehensive physical exam is sometimes referred to as an executive physical. This exam include laboratory tests, pulmonary function testing, chest x-rays, audiograms, EKGs, full-body CAT scans, heart stress tests, mammograms or prostate exams, and a urinalysis.
What is included in an annual physical exam?
Basic vitals including height, weight, hearing, vision, blood pressure, heart rate, body mass index (BMI), and an ears, nose, and throat check. Screenings for certain types of cancer including prostate exams for men and breast exams for women.
What are the 3 components of a complete physical examination?
Elements of a Physical Exam A thorough physical examination covers head to toe and usually lasts about 30 minutes. It measures important vital signs -- temperature, blood pressure, and heart rate -- and evaluates your body using observation, palpitation, percussion, and auscultation.
What is a simple physical exam?
In general, the standard physical exam typically includes: Vital signs: blood pressure, breathing rate, pulse rate, temperature, height, and weight. Vision acuity: testing the sharpness or clarity of vision from a distance. Head, eyes, ears, nose and throat exam: inspection, palpation, and testing, as appropriate.
How can I remember my physical exam?
I PASS stands for Inspection, Palpation, Active ROM (& Passive ROM), Strength, Special Tests. This is a good mnemonic for doing Musculoskeletal exams e.g. shoulder, knee, etc.
What are the questions for a physical?
You should also be prepared to answer some of your doctor's questions, including: How often do you exercise? Do you smoke, drink alcohol, or use any drugs? What is your diet like? Are you feeling any abnormal pain or discomfort? Where do you feel the pain or discomfort? How is your sleep?
What is a regular physical exam?
In general, the standard physical exam typically includes: Vital signs: blood pressure, breathing rate, pulse rate, temperature, height, and weight. Vision acuity: testing the sharpness or clarity of vision from a distance. Head, eyes, ears, nose and throat exam: inspection, palpation, and testing, as appropriate.
What are the 6 parts that an annual physical check up may include?
Here's what to expect from an annual well-check. Measure height and weight. Check vital signs. Review personal health concerns. Review medical care preferences. Assess your social environment and how it affects your health. Review your medication list. Review family health history. Have an actual physical exam.
Related pages
Related to physical form
Related Catalogs
If you believe that this page should be taken down, please follow our DMCA take down process
here
.
This form may include fields for payment information. Data entered in these fields is not covered by PCI DSS compliance.