Adult Physical Exam Form

Adult Physical Exam Form
Name
First NameLast Name
Birthdate
MonthDayYear
Date
Date
MonthDayYear
Date
Current Medication List
Medication Name Mg/Dosage Reason
1
2
3
4
5
Past Medication List
Medication Name Mg/Dosage Date(from) Date(to) Reason
1
2
3
4
5
Do you have an operation of a surgery experience?
YesNo
If yes, please list them all.
Mark if you have any of these conditions currently or in the past.
Weight lossFatigueMemory LossHeadacheVisual LossDecreased HearingSinus PainHoarsenessSore ThroatTrouble SwallowingBreast MassBreast PainSkin ChangesAnemiaChest PainIrregular Heart BeatElevated Blood PressureHeart DiseaseShortness of BreathSwelling of LimbsDiabetesExcessive ThirstExcessive UrinationBloody StoolConstipationDiarrheaHeart BurnJaundiceKidney StonesNausea VomitingLibido ChangeStrokeAnxietyDepressionSleep IssuesOther
Do you smoke?
YesNo
Do you have any allergies?
YesNo
If yes, please list them all.
How much coffee, tea, or carbonated beverage do you drink daily?
How many beers, mixed drinks, or glasses of wine do you have weekly?

Family History