Yearly Physical
Name
Date
Allergies
DOB
Age
Height
Weight
Blood pressure
Pulse
LMP
Problems Addressed	Medications	Rxs Written
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
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 ( if done today, or WS for “will schedule”)
Immunizations	Td	Flu	Pneumovax	Hep.B	Hep.C	Varicella
Lab	CBC	Chem	TSH	PSA	Lipid profile
U/A	Hemoccults	Other
Pap	GC/CT
Mammogram	Bone density
Flex. sig.	Treadmill	Ophthalmology
Other Recommendations/Referrals
Follow- up
Next physical

Name
Date
DOB
Age
Additional History Discussed
( Update family history	( Update surgeries
ROS	( HEENT	( Gastrointestinal	( General
( Cardiovascular	( Genitourinary	( Psychiatric
( Respiratory	( Neuromuscular	( Derm.
Physical Exam
Head
Heart
Extremities
Eyes
Lungs
Scrotum
Ears
Breasts
Penis
Nose
Abdomen
Hernia
Throat
Vulva
Prostate
Thyroid
Vagina
Rectal
Nodes
Cervix
Carotids
Uterus
Skin
Adnexae

2002-11-18

Microsoft Corporation