YEARLY PHYSICAL

NAME *Patient Name+

DOB

AGE *age+

DATE

ALLERGIES _______________________________________________________________________________________
HEIGHT _______

WEIGHT __________ BLOOD PRESSURE ___________ PULSE _________ LMP __________

PROBLEMS ADDRESSED ____________________________________________________________________________

MEDICATIONS ___________________________________________________________________________________
RXS WRITTEN ____________________________________________________________________________________
RISK FACTORS REVIEWED

1.
2.
3.
4.
5.
6.
7.
8.

Diet
Exercise
Safety (seat belts, smoke detectors, firearms, violence)
Smoking
Alcohol and other drugs
STDs/Contraception
Advanced directive
*Other+

DISEASE PREVENTION AND RECOMMENDATIONS

1.
2.
3.
4.
5.

Stroke and coronary disease (BP, cholesterol, weight, stress, aspirin - 81 mg./day)
Cancer (diet, vitamin C- 500 mg., E - 400 units)
Osteoporosis (exercise, calcium - 1500 mg., vitamin D - 400 units, estrogen)
Viruses and colds (wash hands, vitamin C 500-1000 mg., Echinacea, fluids, zinc)
*Other+

HEALTH MAINTENANCE (enter date or check WS for will schedule)

IMMUNIZATIONS

Td
Flu
Pneumovax
Hep.B
Hep.C
Varicella
*Other+
*Other+

LAB

____ | WS
____ | WS
____ | WS
____ | WS
____ | WS
____ | WS
____ | WS
____ | WS

OTHER

CBC
Chem
TSH
PSA
Lipid profile
U/A
Hemoccults
*Other+

____ | WS
____ | WS
____ | WS
____ | WS
____ | WS
____ | WS
____ | WS
____ | WS

Pap
GC/CT
Mammogram
Bone density
Flex. sig.
Treadmill
Ophthalmology
*Other+

____ | WS
____ | WS
____ | WS
____ | WS
____ | WS
____ | WS
____ | WS
____ | WS

OTHER RECOMMENDATIONS/REFERRALS
FOLLOW-UP ______________________

| NEXT PHYSICAL __________________

ADDITIONAL HISTORY DISCUSSED

_______________________________________________________________________________________________
Update family history ___________________________________________________________________________
Update surgeries _______________________________________________________________________________

NAME *DOB+

DOB

AGE *age+

DATE
pg. 2

ROS

Derm.
Gastrointestinal
General

Cardiovascular
Genitourinary
HEENT

Neuromuscular
Psychiatric
Respiratory

Heart ______________________
Lungs ______________________
Breasts _____________________
Abdomen ___________________
Vulva ______________________
Vagina _____________________
Cervix _____________________
Uterus _____________________
Adnexae ____________________

Extremities ___________________
Scrotum _____________________
Penis _______________________
Hernia ______________________
Prostate _____________________
Rectal _______________________

PHYSICAL EXAM

Head ______________________
Eyes _______________________
Ears _______________________
Nose ______________________
Throat _____________________
Thyroid ____________________
Nodes _____________________
Carotids ____________________
Skin _______________________