Annual Update Form- Male
Please complete prior to your annual physical exam.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of last complete physical
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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?
*
No
Yes (specify)
Since you were here last, have you had surgery?
*
No
Yes (specify)
Since you were here last, have you been in a skilled nursing or rehabilitation facility?
*
No
Yes (specify)
Since you were here last, have you seen any physicians that we did not refer you to?
*
No
Yes (specify)
Are you allergic to any medications?
*
No
Yes (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
*
Married
Divorced
Widowed
Single
Separated
Partnered
What is your occupation?
What are your hobbies?
What is your church affiliation?
Do you exercise regularly?
*
No
Yes
How often do you exercise?
*
What type of exercise?
*
Do you smoke or use other tobacco products?
*
No
Yes
How many packs per day?
*
How many years have you smoked or used tobacco products?
*
Do you drink alcohol (beer, wine, liquor)?
*
No
Yes
How many alcoholic drinks per day?
*
Do you use recreational drugs?
*
No
Yes
What kind of recreational drugs do you use, and how often?
*
Are you visually impaired?
*
No
Yes
Do you wear glasses or contacts?
*
No
Yes
Do you wear hearing aids or are you hard of hearing?
*
No
Yes
When was your last colon exam?
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Leave blank if unsure or not applicable
When was your last bone density exam?
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Leave blank if unsure or not applicable
When was your last TB skin test?
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Leave blank if unsure or not applicable
When was your last flu shot?
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Leave blank if unsure or not applicable
When was your last Pneumovax shot?
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Leave blank if unsure or not applicable
When was your last tetanus shot?
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Leave blank if unsure or not applicable
When was your last Covid shot?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Leave blank if unsure or not applicable
Which manufacturer was your Covid shot?
Please Select
Moderna
Pfizer
Johnson & Johnson
Have any of your blood relatives had the following? (Select all that apply)
*
Asthma
Kidney disease
Migraine headaches
Cancer
Dementia/memory loss
Anemia/low blood
Epilepsy/seizures
Tuberculosis
Immune disease
Diabetes/blood sugar problems
Rheumatic fever
High cholesterol
Goiter/thyroid disease
High blood pressure
Osteoporosis
Arthritis
Heart disease
None of the following
Review of Systems
General: Have you experienced any of the following problems? (Select all that apply)
*
Weight loss
Appetite loss
Fever
Night sweats
Fatigue
Skin changes
Rash
Change in wart/mole
I have not experienced these problems
HEENT: Have you experienced any of the following problems? (Select all that apply)
*
Blurred vision
Headache
Double vision
Hearing loss
Ringing in the ears
Vertigo
Nose bleed
Seasonal allergies
Bleeding gums
Hoarseness
I have not experienced these problems
Respiratory: Have you experienced any of the following problems? (Select all that apply)
*
Cough
Decreased exercise tolerance
Snoring
Difficulty breathing
Wheezing
I have not experienced these problems
Breast: Have you experienced any of the following problems? (Select all that apply)
*
Breast mass
Breast pain
Nipple discharge
I have not experienced these problems
Cardiovascular: Have you experienced any of the following problems? (Select all that apply)
*
Chest pain
Difficulty breathing/exert
Irregular heart beat
Elevated blood pressure
Shortness of breath
Swelling of extremities
I have not experienced these problems
Gastrointestinal: Have you experienced any of the following problems? (Select all that apply)
*
Abdominal pain
Change in bowel habits
Constipation
Diarrhea
Difficulty swallowing
Heartburn
Rectal bleeding
I have not experienced these problems
Male Genitourinary: Have you experienced any of the following problems? (Select all that apply)
*
Change in urinary system
Frequency
Blood in urine
Impotence
Incontinence
Painful urination
Urinating at night
Sexually active
Testicular pain
I have not experienced these problems
Musculoskeletal: Have you experienced any of the following problems? (Select all that apply)
*
Back pain
Joint pain
Joint stiffness
Joint swelling
Muscle pain
Muscle weakness
Osteoporosis
Recent injury
I have not experienced these problems
Neurological: Have you experienced any of the following problems? (Select all that apply)
*
Dizziness
Fainting
Headaches
Numbness or tingling
Seizures
Tremor
Vertigo
Weakness
I have not experienced these problems
Psychiatric: Have you experienced any of the following problems? (Select all that apply)
*
Anxiety
Crying spells
Depression
Mood changes
Insomnia
I have not experienced these problems
Endocrine: Have you experienced any of the following problems? (Select all that apply)
*
Cold intolerance
Excessive thirst
Excessive urination
Heat intolerance
I have not experienced these problems
Hematology: Have you experienced any of the following problems? (Select all that apply)
*
Anemia
Easy bruising
Enlarged lymph nodes
I have not experienced these problems
Submit
Should be Empty: