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...
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