Yearly Physical Exam Online Form

Yearly Physical Exam Online.docx Doctors can use this form template to record notes from an annual physical examination. The form records patient’s vital statistics, medications, risk factors, disease

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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]