Yearly Physical Exam Online Form

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YEARLY PHYSICAL
NAME [Patient Name]
DOB [DOB]
AGE [age]
DATE [date | time]
ALLERGIES [Comments]
HEIGHT [height]
WEIGHT [weight]
BLOOD PRESSURE [BP]
PULSE [pulse]
LMP [LMP]
PROBLEMS ADDRESSED [Comments]
MEDICATIONS [Comments]
RXS WRITTEN [Comments]
RISK FACTORS REVIEWED
1. Diet
2. Exercise
3. Safety (seat belts, smoke detectors, firearms, violence)
4. Smoking
5. Alcohol and other drugs
6. STDs/Contraception
7. Advanced directive
8. [Other]
DISEASE PREVENTION AND RECOMMENDATIONS
1. Stroke and coronary disease (BP, cholesterol, weight, stress, aspirin – 81 mg./day)
2. Cancer (diet, vitamin C- 500 mg., E – 400 units)
3. Osteoporosis (exercise, calcium – 1500 mg., vitamin D – 400 units, estrogen)
4. Viruses and colds (wash hands, vitamin C – 500-1000 mg., Echinacea, fluids, zinc)
5. [Other]
HEALTH MAINTENANCE (enter date or check WS for ‘will schedule’)
IMMUNIZATIONS LAB OTHER
Td [date] | • WS
CBC [date] | • WS
Pap [date] | • WS
Flu [date] | • WS
Chem [date] | • WS
GC/CT [date] | • WS
Pneumovax [date] | • WS
TSH [date] | • WS
Mammogram [date] | • WS
Hep.B [date] | • WS
PSA [date] | • WS
Bone density [date] | • WS
Hep.C [date] | • WS
Lipid profile [date] | • WS
Flex. sig. [date] | • WS
Varicella [date] | • WS
U/A [date] | • WS
Treadmill [date] | • WS
[Other]
[date] | • WS
Hemoccults [date] | • WS
Ophthalmology [date] | • WS
[Other]
[date] | • WS
[Other]
[date] | • WS
[Other]
[date] | • WS
OTHER RECOMMENDATIONS/REFERRALS [Recommendations/referrals]
FOLLOW-UP [Follow-up] | NEXT PHYSICAL [date | time]
ADDITIONAL HISTORY DISCUSSED
[Comments]
• Update family history [Comment]
• Update surgeries [Comment]
ROS
• Derm. [Comment]
• Gastrointestinal [Comment]
• General [Comment]
• Cardiovascular [Comment]
• Genitourinary [Comment]
• HEENT [Comment]
• Neuromuscular [Comment]
• Psychiatric [Comment]
• Respiratory [Comment]
PHYSICAL EXAM
Head [Comment]
Eyes [Comment]
Ears [Comment]
Nose [Comment]
Throat [Comment]
Thyroid [Comment]
Nodes [Comment]
Carotids [Comment]
Skin [Comment]
Heart [Comment]
Lungs [Comment]
Breasts [Comment]
Abdomen [Comment]
Vulva [Comment]
Vagina [Comment]
Cervix [Comment]
Uterus [Comment]
Adnexae [Comment]
Extremities [Comment]
Scrotum [Comment]
Penis [Comment]
Hernia [Comment]
Prostate [Comment]
Rectal [Comment]