Annual Update Form- Female

Annual Update Form- Female

Please complete prior to your annual physical exam.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Date of last complete physical

MonthDayYear
Date
Medical History
What major health concerns do we need to discuss today?*
Is there anything that makes it hard for your to take care of your health?*
Since you were here last, have you been in the hospital or emergency room?*

NoYes (specify)
Since you were here last, have you had surgery?*

NoYes (specify)
Since you were here last, have you been in a skilled nursing or rehabilitation facility?*

NoYes (specify)
Since you were here last, have you seen any physicians that we did not refer you to?*

NoYes (specify)
Are you allergic to any medications?*

NoYes (specify)
What medications are you currently taking? Please list medication names and doses.*
Please list any vitamins, supplements, or herbal products you are taking:
Health Screening
Please indicate your marital status*

MarriedDivorcedWidowedSingleSeparatedPartnered
What is your occupation?
What are your hobbies?
What is your church affiliation?
Do you exercise regularly?*

NoYes
How often do you exercise?*
What type of exercise?*
Do you smoke or use other tobacco products?*

NoYes
How many packs per day?*
How many years have you smoked or used tobacco products?*
Do you drink alcohol (beer, wine, liquor)?*

NoYes
How many alcoholic drinks per day?*
Do you use recreational drugs?*

NoYes
What kind of recreational drugs do you use, and how often?*
Are you visually impaired?*

NoYes
Do you wear glasses or contacts?*

NoYes
Do you wear hearing aids or are you hard of hearing?*

NoYes
When was your last colon exam?

MonthDayYear
Leave blank if unsure or not applicable
When was your last bone density exam?

MonthDayYear
Leave blank if unsure or not applicable
When was your last TB skin test?

MonthDayYear
Leave blank if unsure or not applicable
When was your last flu shot?

MonthDayYear
Leave blank if unsure or not applicable
When was your last Pneumovax shot?

MonthDayYear
Leave blank if unsure or not applicable
When was your last tetanus shot?

MonthDayYear
Leave blank if unsure or not applicable
When was your last Covid shot?

MonthDayYear
Leave blank if unsure or not applicable
Which manufacturer was your Covid shot?
Have any of your blood relatives had the following? (Select all that apply)*

AsthmaKidney diseaseMigraine headachesCancerDementia/memory lossAnemia/low bloodEpilepsy/seizuresTuberculosisImmune diseaseDiabetes/blood sugar problemsRheumatic feverHigh cholesterolGoiter/thyroid diseaseHigh blood pressureOsteoporosisArthritisHeart diseaseNone of the following
Review of Systems
General: Have you experienced any of the following problems? (Select all that apply)*

Weight lossAppetite lossFeverNight sweatsFatigueSkin changesChange in wart/moleI have not experienced these problems
HEENT: Have you experienced any of the following problems? (Select all that apply)*

Blurred visionHeadacheDouble visionHearing lossRinging in the earsVertigoNose bleedSeasonal allergiesBleeding gumsHoarsenessI have not experienced these problems
Respiratory: Have you experienced any of the following problems? (Select all that apply)*

CoughDecreased exercise toleranceSnoringDifficulty breathingWheezingI have not experienced these problems
Breast: Have you experienced any of the following problems? (Select all that apply)*

Breast massBreast painNipple dischargeI have not experienced these problems
Cardiovascular: Have you experienced any of the following problems? (Select all that apply)*

Chest painDifficulty breathing/exertIrregular heart beatElevated blood pressureShortness of breathSwelling of extremitiesI have not experienced these problems
Gastrointestinal: Have you experienced any of the following problems? (Select all that apply)*

Abdominal painChange in bowel habitsConstipationDiarrheaDifficulty swallowingHeartburnRectal bleedingI have not experienced these problems
Female Genitourinary: Have you experienced any of the following problems? (Select all that apply)*

Urinary complaintsAbsence of menstruationBlood in urineExcess menstrual bleedingIncontinenceLeaking urinePainful intercourseSexually activeUrethral dischargeVaginal bleedingI have not experienced these problems
Musculoskeletal: Have you experienced any of the following problems? (Select all that apply)*

Back painJoint painJoint stiffnessJoint swellingMuscle painMuscle weaknessOsteoporosisRecent injuryI have not experienced these problems
Neurological: Have you experienced any of the following problems? (Select all that apply)*

DizzinessFaintingHeadachesNumbness or tinglingSeizuresTremorVertigoWeaknessI have not experienced these problems
Psychiatric: Have you experienced any of the following problems? (Select all that apply)*

AnxietyCrying spellsDepressionMood changesInsomniaI have not experienced these problems
Endocrine: Have you experienced any of the following problems? (Select all that apply)*

Cold intoleranceExcessive thirstExcessive urinationHeat intoleranceI have not experienced these problems
Hematology: Have you experienced any of the following problems? (Select all that apply)*

AnemiaEasy bruisingEnlarged lymph nodesI have not experienced these problems
Should be Empty:

Annual Update Form- Female

Medical History

Health Screening

Review of Systems