ANNUAL 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]