Adult Physical Exam Form
Name
First Name
Last Name
Birthdate
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Medication List
Rows
Medication Name
Mg/Dosage
Reason
1
2
3
4
5
Past Medication List
Rows
Medication Name
Mg/Dosage
Date(from)
Date(to)
Reason
1
2
3
4
5
Do you have an operation of a surgery experience?
Yes
No
If yes, please list them all.
Mark if you have any of these conditions currently or in the past.
Weight loss
Fatigue
Memory Loss
Headache
Visual Loss
Decreased Hearing
Sinus Pain
Hoarseness
Sore Throat
Trouble Swallowing
Breast Mass
Breast Pain
Skin Changes
Anemia
Chest Pain
Irregular Heart Beat
Elevated Blood Pressure
Heart Disease
Shortness of Breath
Swelling of Limbs
Diabetes
Excessive Thirst
Excessive Urination
Bloody Stool
Constipation
Diarrhea
Heart Burn
Jaundice
Kidney Stones
Nausea Vomiting
Libido Change
Stroke
Anxiety
Depression
Sleep Issues
Other
Do you smoke?
Yes
No
Do you have any allergies?
Yes
No
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
Rows
Mother
Father
Brother/sister
Grandfather
Grandmother
Other Relatives
Alcoholism
1
2
3
4
5
6
Allergies
7
8
9
10
11
12
Diabetes
13
14
15
16
17
18
Tuberculosis
19
20
21
22
23
24
Heart Disease
25
26
27
28
29
30
Stroke
31
32
33
34
35
36
High Blood Pressure
37
38
39
40
41
42
Depression / Anxiety / Bipolar
43
44
45
46
47
48
Cancer
49
50
51
52
53
54
High Cholesterol
55
56
57
58
59
60
Thyroid issues
61
62
63
64
65
66
Additional Notes
Submit
Should be Empty: