Sample Yearly Physical Form
The Yearly Physical Form (Sample) is available below to download, customize and print for your business office, Human Resources Department in your small business and/or organization.
Do you have employees?
If yes, then your small business or organization probably has annual physicals you require for all your employees.
A routine physical exam mostly consists of:
- History – This includes your medical history and your families medical history.
- Vital Signs – Checking your blood pressure, heart rate, respiration rate, temperature.
- General Appearance – Doctor gathers a large amount of information of you and your health just by watching and talking to you.
- Heart Exam – Dr. will listen to your heart with a stethoscope.
- Lung Exam – Dr. will use the stethoscope to listen for crackles, wheezes, or decreased breath sounds.
Every physical exam can differ but they mostly consist of the above procedures.
The Annual Physical Form below includes:
- Title of Form – Yearly Physical
- Patient Information – Patient Name, DOB, Age, Allergies, Height, Weight, Blood Pressure, Pulse, LMP
- Problems Addressed – Comments are entered here by physician or nurse.
- Medications – List of medications are entered here by physician or nurse.
- RXS Written – List of prescriptions that physician ordered are entered here.
- 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, vitamin D – 400 units, estrogen) – See form below for more information.
- Health Maintenance – (Enter date or check WS for “Will schedule”) – Includes Immunizations (listed on form), Lab (listed on form), and Other (Pap, GC/CT, Mammogram, Bone Density, Fex. sig., Treadmill, Ophthalmology, Other)
- Other Recommendations/Referrals – Enter recommendations/referrals here.
- Follow-Up – Enter date.
- Next Physical – Enter date and time.
- Additional History Discussed – Dr will enter comments here.
- Update Family History – Enter comments here.
- Update Surgeries – Enter comments here.
- ROS – Dr will enter comments on each one (derm, gastrointestinal, general, cardiovascular, genitourinary, HEENT, neuromuscular, physchiatric, respiratory)
- Physical Exam – Dr will enter comments on each one (Head, eyes, ears, nose, throat, thyroid, nodes, carotids, skin, heart, lungs, breasts, abdomen, vulva….)
- Dr. Name/Signature or ARNP Name/Signature