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Free Annual Medical Report

This 2-page annual medical report contains sections for documenting a patient's date of examination, personal information, diagnoses, physical exam findings, screening tests, immunizations, medications, risk factors, and the physician's recommendations. Key information includes the patient's temperature, height, weight, blood pressure, and results from eye, lung, heart, and neurological exams. Screening sections address cancer, prostate, female, and other exams. Immunizations include tetanus, pneumococcal, influenza, and measles. The physician certifies no communicable diseases and provides recommendations for further work, treatment, and other health issues.

Uploaded by

Pravin Nikhade
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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873 views2 pages

Free Annual Medical Report

This 2-page annual medical report contains sections for documenting a patient's date of examination, personal information, diagnoses, physical exam findings, screening tests, immunizations, medications, risk factors, and the physician's recommendations. Key information includes the patient's temperature, height, weight, blood pressure, and results from eye, lung, heart, and neurological exams. Screening sections address cancer, prostate, female, and other exams. Immunizations include tetanus, pneumococcal, influenza, and measles. The physician certifies no communicable diseases and provides recommendations for further work, treatment, and other health issues.

Uploaded by

Pravin Nikhade
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

Annual Medical Report Page 1 of 2

Date of Medical Examination:

Name:

Address:
(Street) (City) (Zip Code)

Date of Birth: Sex: Male Female

Diagnosis:

General Physical Description:

Known Allergies:

Please fill information in for all areas that apply:

Temperature Height Weight Blood Pressure Pulse

Respiration Cholesterol Eyes Nose Throat

Ears Chest Lungs Heart

Male Screenings: Prostate-Specific Antigen: Genital Development/Exam


(Please list dates) Exam:

Female Screenings: Pap Smear: Breast Exam: Mammography:


(Please list dates)
Genital Development/Exam

Other Screenings/Tests: (Please list dates)

Vision: _ Urinalysis: Colonoscopy:

Hearing: _ Sigmoidoscopy: Extremities:

Dental: Stool Occult Blood: Abdomen:

Hernia: Spine:

AtlantoAxial Instability Findings (Down Syndrome):

EXAM FOR CANCER: Type: Positive Neurological Findings:

Last:

Type and Frequency of seizures:


Page 2 of 2
Immunizations:

Tetanus-Diphtheria: Hepatitis Testing Results:

Pneumococcal: Hepatitis B Immunization Series: Initial:


30 days:
Influenza: 6 months:

Measles: TB Skin Test Results:

Current Medications and Reasons:

Other Risk Factors (Check all that apply)


Yes No
High Blood Pressure
High LDL cholesterol
Low HDL cholesterol
High Triglycerides
High Blood Glucose

Family History of:


Premature Heart Disease
Physical Inactivity
Cigarette Smoking

Recommendations:

Further diagnostic Work (Serology, X-Ray, Etc.):

Treatment (including Immunizations):

Other Recommendations:

Communicable Disease: I certify that no communicable disease is evident at the time of


this examination.

Date:
Physician Signature

Please Print Physician’s Name

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