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Vero Scribe writes the annual physical in your template from the visit conversation, with the patient’s consent, or from your dictation. You review and edit it, then copy it into your EHR or export it to PDF or Word.
Annual Physical Exam Template
An annual physical exam note records a preventive visit: what has changed, which screening and vaccines are due, lifestyle risks, a full examination, and the plan. Copy the free template, see two filled examples, and check what goes in each part.
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- Two filled examples
Blank annual physical exam template
FreeANNUAL PHYSICAL EXAM Patient: [Name] Date of birth: [Date] Date of visit: [Date] Clinician: [Name, credentials] Last preventive visit: [Date, or how long ago] INTERVAL HISTORY Patient's concerns: [Questions or symptoms raised today, in the patient's words] Since the last visit: [New diagnoses, emergency or hospital visits, surgeries, specialist care] Chronic conditions: [Each condition and its status, or reviewed in a separate visit] Medications: [Prescriptions, over-the-counter drugs, and supplements, with adherence] Allergies: [Drug and other allergies, with reactions] Family history: [New diagnoses in first-degree relatives, with age at diagnosis] Review of systems: [Pertinent positives and negatives] PREVENTIVE CARE REVIEW Cancer screening: [Each test due per current guidelines for age, sex, and risk, with the date and result of the last one, or declined] Cardiometabolic screening: [Blood pressure history, lipids, diabetes screening, and a cardiovascular risk score if calculated] Other screening: [Bone density, vision, hearing, or infections, as indicated by age and risk] Immunizations: [Each vaccine: up to date, given today, due, or declined] Sexual and reproductive health: [Contraception, pregnancy plans, menopause or prostate questions, and STI testing if indicated] LIFESTYLE AND MENTAL HEALTH Diet: [Usual eating pattern, sugary drinks, restrictions] Physical activity: [Type, and minutes per week] Sleep: [Hours per night, quality, snoring, daytime sleepiness] Tobacco and nicotine: [Never, former, or current, with pack-years and readiness to quit] Alcohol: [Drinks per week, the most on one day, and a screening score if used, such as AUDIT-C] Other substances: [Cannabis or other drug use] Depression screen: [Tool and score, such as PHQ-2 or PHQ-9] Anxiety and stress: [Tool and score if used, such as GAD-7, and current stressors] Cognition: [Concerns raised, and screening if indicated] Safety: [Seat belts, helmets, falls, safe storage of firearms and medications, intimate partner safety] PHYSICAL EXAMINATION Vital signs: [BP, repeated if high, HR, RR, temperature, SpO2] Measurements: [Height, weight, BMI, waist circumference] General: [Appearance] HEENT: [Eyes, ears, nose, mouth, teeth] Neck: [Thyroid, lymph nodes] Cardiovascular: [Heart sounds, peripheral pulses, edema] Respiratory: [Breath sounds] Abdomen: [Tenderness, masses, organ enlargement] Breast and genitourinary: [Findings, or deferred and why, and any chaperone present] Musculoskeletal: [Joints, spine, gait] Skin: [Lesions of concern] Neurological: [Strength, sensation, reflexes, as examined] ASSESSMENT Health status: [Overall summary, such as healthy adult or adult with the chronic conditions listed] Risks identified: [Cardiovascular, cancer, metabolic, fracture, mental health, or other] New findings: [Each new problem found today, numbered] PLAN Screening: [Tests ordered or referred, per current guidelines for age, sex, and risk] Immunizations: [Vaccines given today, and doses still due] Labs: [Blood work ordered, with the reason for each] Counseling: [Topics covered, and the goal the patient chose] New findings: [Plan for each, or a separate visit booked] Follow-up: [Next preventive visit, earlier visits, and how results will be shared] Signed: [Clinician name, credentials, date and time]
Use it for
- Annual physicals
- Wellness visits
- Periodic health exams
- New adult patients
- Preventive care reviews
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Annual physical exam: healthy 35-year-old woman
Primary care, preventive visit
Interval history
35-year-old woman for her physical; last preventive visit 14 months ago. Asks about a mole on her upper back that her partner noticed; she isn’t sure whether it has changed. No new diagnoses, emergency visits, or surgeries. No chronic conditions. Levonorgestrel IUD placed 2 years ago, no problems; no other medications or supplements. No known drug allergies. Family history: mother developed type 2 diabetes at 52; father has hypertension; no breast, ovarian, or colon cancer. Review of systems negative apart from tiredness by the end of the work week, which she puts down to short sleep.
Preventive care review
Cervical screening: last result normal 5 years ago; due now. Breast and colorectal screening: not yet due at average risk. Cardiometabolic: blood pressure normal at past visits; diabetes screening due because of her mother’s history. Immunizations: tetanus booster 6 years ago; influenza vaccine due. Sexual and reproductive health: one partner for 6 years, no concerns, no pregnancy plans for now; HIV and STI testing offered per current guidelines, declined.
Lifestyle and mental health
Mostly home-cooked meals; two sweetened coffees a day. Walks 20 minutes on 3 days a week; no strength training. Sleeps about 6 hours on work nights; no snoring. Never smoked or vaped. Alcohol: 1 or 2 drinks on weekends, never more than 2 at a time. Cannabis edible about once a month. PHQ-2 score 0. Busy at work but coping; no anxiety symptoms. Wears a seat belt and a bike helmet; no firearms at home; feels safe in her relationship.
Physical examination
BP 114/72, HR 68, RR 14, T 36.7 °C (98.1 °F), SpO2 99% on room air. Height 165 cm (65 in), weight 64 kg (141 lb), BMI 23.5, waist 78 cm (31 in). Well appearing. Eyes, ears, mouth, and teeth normal. Thyroid not enlarged; no lymph nodes. Heart and lungs normal. Abdomen soft, no masses. Speculum exam with a chaperone present: cervix normal in appearance, screening sample taken. Breast exam not done; no concerns raised. Skin: 4 mm round, evenly brown macule with a smooth, regular border on the upper back; no other lesions of concern. Joints, gait, and neurological screen normal.
Assessment
Healthy 35-year-old woman. Benign-appearing nevus on the upper back. Risks: family history of type 2 diabetes; physical activity below recommended levels; short sleep on work nights.
Plan
Cervical screening sample sent. A1c ordered for diabetes screening. Influenza vaccine given today. Counseling: she chose to build up to 150 minutes of walking a week with strength exercises twice a week, to aim for 7 hours of sleep on work nights, and to switch to one unsweetened coffee a day. Nevus: monthly self-checks; return for any change in size, shape, or color, bleeding, or itching. Results by phone or the patient portal. Next preventive visit as recommended for her age and risk, sooner for any new concern.
Annual physical exam: 62-year-old man with hypertension
Primary care, preventive visit
Interval history
62-year-old man for his physical; last one 2 years ago. Hypertension for 8 years on amlodipine 5 mg daily, taken every day; home readings average 128/80. No chest pain, breathlessness, or ankle swelling. His wife says his snoring has become loud. No new diagnoses or hospital visits. No known drug allergies. Family history: father had a heart attack at 70; no colon or prostate cancer.
Preventive care review
Colorectal screening: never done; due per current guidelines for his age, at average risk. Options discussed; he prefers a fecal immunochemical test (FIT) to colonoscopy. Prostate cancer screening: benefits and harms of PSA testing discussed; he prefers not to be tested now. Cardiometabolic: lipids and A1c last checked 3 years ago, normal; due. Lung cancer and aortic aneurysm screening: not indicated now by age and smoking history. Immunizations: tetanus booster 4 years ago; pneumococcal vaccine at a pharmacy last year; no zoster vaccine; influenza vaccine due.
Lifestyle and mental health
Takeout 3 to 4 times a week; adds salt at the table. Walks the dog 15 minutes a day. Sleeps 7 hours; loud snoring, no witnessed pauses in breathing, sleepy most afternoons. Former smoker, about 10 pack-years, quit 25 years ago. Alcohol: about 10 drinks a week, up to 5 on a Saturday. No cannabis or other drugs. PHQ-2 score 0. No memory concerns. Wears a seat belt; no falls.
Physical examination
BP 136/84, repeat 132/82 after 5 minutes’ rest; HR 72, RR 14, T 36.8 °C (98.2 °F), SpO2 97% on room air. Height 178 cm (70 in), weight 96 kg (212 lb), BMI 30.3, waist 106 cm (42 in), neck 43 cm (17 in). Well appearing. Crowded oropharynx. Thyroid normal; no lymph nodes. Heart regular, no murmurs. Lungs clear. Abdomen soft, no masses, no pulsatile mass. Pedal pulses present, no edema. Skin: seborrheic keratoses on the back, no lesions of concern. Genitourinary exam not done: no symptoms. Gait and neurological screen normal.
Assessment
Adult with hypertension, controlled on home readings. Risks: obesity, BMI 30.3; alcohol use above low-risk levels; possible obstructive sleep apnea, STOP-Bang score 6. Due for colorectal, diabetes, and lipid screening, and for zoster and influenza vaccines. 10-year cardiovascular risk to be calculated when lipids are back.
Plan
FIT kit given, with colonoscopy if positive. A1c, lipid profile, creatinine, and electrolytes ordered. Influenza vaccine and recombinant zoster vaccine dose 1 given today; dose 2 in 2 to 6 months. Referred for a sleep study; advised not to drive when drowsy. Brief alcohol intervention: he chose to drink on weekends only, no more than 2 drinks a day. Counseling on less takeout and salt, and building up to 150 minutes of walking a week. Continue amlodipine 5 mg daily and home readings. PSA testing can be revisited at any visit. Follow-up in 4 weeks for results and his cardiovascular risk.
What goes in each part.
Interval history
What has happened since the last preventive visit, and what the patient wants to talk about. Ask for concerns first: patients often save one for the physical.
- Concerns raised today, in the patient’s words
- New diagnoses, hospital visits, and specialist care
- Medications and supplements, gone through with the patient
- Family history updates, with age at diagnosis
- Pertinent positives and negatives on review of systems
Avoid: Carrying last year’s medication list forward without going through it with the patient.
Preventive care review
Which screening tests and vaccines are due for this patient’s age, sex, and risk, and where each one stands.
- Each screening test due under the guidelines you follow
- The date and result of the last one
- Vaccines given, due, or declined
- Contraception, pregnancy plans, and sexual health
- Shared decisions, such as PSA testing, and the patient’s choice
Avoid: Pasting in a fixed screening schedule instead of checking current guidelines against this patient’s risk.
Lifestyle and mental health
The habits and pressures that shape long-term risk, in numbers where you can, with a named mental health screen.
- Diet, and activity in minutes per week
- Sleep, snoring, and daytime sleepiness
- Tobacco in pack-years; alcohol in drinks per week
- A named depression screen and its score, such as the PHQ-2 or PHQ-9
- Safety: seat belts, falls, firearms, and intimate partner safety
Avoid: Writing “screen negative” without the name of the tool and the score.
Physical examination
A complete exam by system, scaled to the patient’s age, risk, and concerns.
- Vital signs, with a repeat blood pressure if the first is high
- Height, weight, BMI, and waist circumference
- Each system you examined, with its findings
- Sensitive exams deferred, with the reason, and any chaperone
Avoid: Recording a single high blood pressure reading without a repeat after rest.
Assessment
A summary of the patient’s health and the risks you found, rather than just “annual exam.”
- Overall health status
- Risk factors identified, by type
- New findings that need follow-up, numbered
Avoid: Naming a new finding, like a positive sleep apnea screen, with no matching line in the plan.
Plan
What was ordered, given, and agreed, and when the patient comes back.
- Screening ordered or referred
- Vaccines given today, and doses still due
- Labs, each with a reason
- Counseling, with the goal the patient chose
- How results will be shared, and the next visit
Avoid: Ordering a routine blood panel because it’s the physical, rather than for the patient’s age, sex, and risk.
Common mistakes, and how to avoid them.
Leaving the patient’s concern to the end
A worry raised at the door gets a rushed answer. Ask for concerns at the start, and book a separate visit for any that need more time.
“Up to date” with no dates
Record each screening test with its date and result, or the reason it was declined, so the next review doesn’t start from scratch.
Hiding problem care in the physical
Medication changes for a chronic condition are easy to miss in a preventive note. Give them their own clear lines, or a separate follow-up note.
A normal exam you didn’t do
Macros fill every system with normal findings. Edit them to match today’s exam, and say what you deferred and why.
Counseling with no goal
“Discussed diet and exercise” can’t be followed up. Record the goal the patient chose, in numbers where you can.
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Frequently asked questions.
What should an annual physical exam note include?
The interval history, a review of the screening and vaccines due, lifestyle and a mental health screen, a full examination, and an assessment and plan with counseling and follow-up. The template has a field for each.
Is an annual physical the same as a wellness visit?
The terms are often used interchangeably. Some payers define a wellness visit more narrowly, as a review of risks and a prevention plan without a full examination, so check how yours defines the visit you are documenting.
Can I manage chronic conditions during an annual physical?
Yes, but keep problem care distinct from preventive care. Note each condition’s status, and record any change to its treatment clearly, or in a separate follow-up note; some payers treat it as a separate service.
Which screening tests should the note list?
Each test that is due for the patient’s age, sex, and risk under the guidelines you follow, with the date and result of the last one, or the reason it was declined. Recommendations change, so check the current guideline rather than a fixed list.
Do I need to examine every system at a physical?
Examine what fits the patient’s age, risks, and concerns, and record only what you examined. If you defer part of the exam, such as a breast or pelvic exam, note it and the reason.
Is this annual physical exam template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
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