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 Diet Exercise Safety (seat belts, smoke detectors, firearms, violence) Smoking Alcohol and other drugs STDs/Contraception Advanced directive [Other]
DISEASE PREVENTION AND RECOMMENDATIONS 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	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]