TAYLOR MADE HOME CARE ANNUAL PHYSICAL EXAMINATION FORM

TAYLOR MADE HOME CARE ANNUAL PHYSICAL EXAMINATION FORM
Please all information to avoid return visits.
Part One: TO BE COMPLETED PRIOR TO MEDICAL APPOINTMENT
Name
Date of Exam

MonthDayYear
Date
Address
SSN
Date of Birth: Name of Accompanying Person:
Date of Birth

MonthDayYear
Date
Name of Accompanying Person
DIAGNOSES/SIGNIFICANT HEALTH CONDITIONS: (Include a Medical History Summary and Chronic Health Problems List, if available)

CURRENT MEDICATIONS: (Attach a second page if needed) Medication Name DoseFrequency

Prescribing Physician Specialty

Does the person take medications independently? Allergies/Sensitivities: Contraindicated Medication:
Allergies/Sensitivities
Contraindicated Medication
IMMUNIZATIONS:
Tetanus/Diphtheria (every 10 years): Hepatitis B: #1 Influenza (Flu): Pneumovax: / Other: (specify)
Type administered
Other: (specify)
TUBERCULOSIS (TBJ SCREENING: (every 2 years by Mantoux method; if positive initial chest x-ray should be done) Date givenDate readResults Chest x-ray (date)Results
Date given

MonthDayYear
Date
Chest x ray (date)

MonthDayYear
Date
Date read

MonthDayYear
Date
Results
Results
Is the person free of communicable diseases?DYesDINo (If no, list specific precautions to prevent the spread of disease to others)
OTHER MEDICAL/LAB/DIAGNOSTIC TESTS:
Date GYN exam wPAP: (women over age 18) Mammogram: (every 2years-women ages 40-49, yearly for women 50 and fover) Prostate Exam: Date: (digital method-males 40 and over) HemoccultDate: UrinalysisDate: CBC/Differential Date: Hepatitis B ScreeningDate: Date: Other (specify Other (specify
Date

MonthDayYear
Date
Results
Date

MonthDayYear
Date
Results
Date

MonthDayYear
Date
Results
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Other (specify).
Results: Results: Results: Results: Results: Date: Date:
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Part Two: GENERAL PHYSICAL EXAMINATION
Pulse
Respirations
Temp
Height
Weight
EVALUATION OF SYSTEMS
Eyes Ears Nose Mouth/Throat Head/Face/Neck Breasts Lungs Cardiovascular Extremities Abdomen Gastrointestinal Musculoskeletal

Integumentary Renal/Urinary Reproductive Lymphatic Endocrine Nervous System
VISION SCREENING
HEARING SCREENING
Is further evaluation recommended by specialist?Yes Is further evaluation recommended by specialist?Yes

Medical history summary reviewed?YesDINo

Medication added, changed, or deleted: (from this appointment)
Special medication considerations or side effects
Recommendations for health maintenance: (include need for lab work at regular intervals, treatments, therapies, exercise, hygiene, weight control, etc.)
Recommendations for manual breast exam or manual testicular exam: (include who will perform and frequency)
Recommended diet and special instructions
Information pertinent to diagnosis and treatment in case of emergency
Limitations or restrictions for activities (including work day, lifting, standing and bending):DNo
Name of Physician (please print)
Physician's Signature

Clear
Physician Phone Number
Should be Empty:

TAYLOR MADE HOME CARE ANNUAL PHYSICAL EXAMINATION FORM

IMMUNIZATIONS:

OTHER MEDICAL/LAB/DIAGNOSTIC TESTS:

EVALUATION OF SYSTEMS

VISION SCREENING

HEARING SCREENING