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Name: Age: Sex: FEMALE/ MALE

Chief Complaint: well patient check up/ annual checkup/ annual exam __________________________
HxCC- when was the last physical____________________ have you been hospitalized recently when was the
last PAP smear/ mammogram/ colonoscopy
PMHx (have you had any childhood illness/injuries; are you diagnosed with having diabetes, HTN, arthritis? Have you
had a heart attack or lung disease?):
PSHx (have you had any surgeries such as an appendectomy, hysterectomy, C-section):
ALL: do you have any food or drug allergies? _______________________ __________________
Meds/ Immuno: are you on any medication? Are your immunizations up to date? When?_______
SocHx: Smokes ETOH Sleep ________ Diet _______ Exercise________ Work
__ Married _Kids Sexually active # Partners Males/Females/Both
General: wgt changes, fatique, insomnia
Skin changes: rashes, lumps, changes in moles
Head: (frequent) headaches, head injuries, dizziness
Eyes: eye pain, blurred vision, vision loss
Ears: hearing loss, ringing, earaches
Nose: nosebleeds, sinus infection, frequent colds
Throat: frequent sore throats, voice changes, hoarseness
Neck: swollen glands, pain, stiffness
CV: chest pain, palpitations, irregular heart beat
Resp: cough, shortness of breath, asthma
GI: heartburn, bleeding, cramping
GU: urinary frequency, burning, incontinence, waking up to use the bathroom; age of menarche________; last
period________; have you had any pregnancies?_________________

GU: testicular pain, penile discharge, bloody urine, hernia, difficulty achieving erections, problems with libido; Last
prostate exam __________

Sexual hx:_have you ever had an STD? Do you have sex with men, women, or both?__________How
many partners have you had in the past 6 months?________________________ What form of protection do you
use?____________Are you on any birth control medication?_________ Do you have any concerns?_______________
Breasts: tenderness, lumps, discharge
MS: muscle pain or stiffness, weakness, decreased ROM, arthritis
Neuro: numbness or tingling in hands/ feet, inability to move your muscles, difficulties with memory or speech
Psych: anxiety, depression, insomnia
Endo/metab: temp intolerance, excessive sweating, night sweats, feeling overly tired
Hem/immuno: easy bruising, frequent illness, delayed wound healing, bleeding

Physical Exam: Wash hands
Vitals: Temp: BP: Pulse: Resp:_________ _______________________________
General: no acute distress ____________
Heart and lung sounds:_______________________________________________________________________________
Head (normocephalic, general appearance, hair pattern):
Eyes (PEARL, red reflex, fundus, eye movement; CN II, III, IV, VI):
Ears (external auditory canal, tympanic membrane):
Nose (septum, mucosal color, discharge):
Throat/mouth (mucosal color, teeth, gums, tongue, pharynx; CN X and CN XII!!):
Neck: (good range of motion, tracheal deviation, thyroid, lymph nodes, bruits):

CV: (rate, rhythm, murmurs, heaves, rubs, bruits, thrills, edema):
Resp: (clarity, thorax symmetry, wheezes or crackles?):
Abd: (look, listen, feel; flat/bowel sounds, guarding, rebound):

Breast: (symmetry, skin changes/dimpling, masses, tenderness, discharge, lymph nodes): ______
Pelvic exam: no lymphadenopathy, no discharge, cervix visualized
Male Genital: (circumcised, discharge, scrotal swelling, descended testes, epididymis tenderness, ing/fem hernia):

MS/OMM: (screen and scan cervical, thoracic, lumbar tissue/motion):

Neuro Exam:
CN II: fundoscopic reflex, visual fields (cover eye one at a time and ask how many fingers)
CN III, IV, and VI: pupillary light reflex, accommodation, H- sign
CN V: face sensory, jaw movement (clench jaw, move from side to side)
CN VII: close eyes against resistance, smile, frown, puff out cheeks
CN VIII: hearing (whisper number in ear and repeat); balance (stand- walk back and forth and observe gait, walk back
and walk on toes, state trooper walk, arms out and palm up with eyes closed)
CN XI: turn head against resistance, shrug shoulders against resistance
CN X: done with examination of the mouth- palate elevation
CN XII: done with examination of the mouth- sticking tongue out and observe that its midline

Reflexes: Biceps tendon, elbow, knees, Achilles tendon, Babinski reflex

Motor: Push and pull arm against resistance, squeeze fingers against resistance, have them squeeze doctors fingers, pat
hands against thigh, roll arms in both directions, touch finger to nose

Summarize: Came for annual checkup, havent been recently hospitalized, hadnt had any surgeries, did/nt have PAP
smear/mammogram/prostate exam/colonoscopy (repeat history, social)
Ask for other concerns
End the visit with a breast and pelvic/ genital and rectal exam

Breast exam/ pelvic: (gown down to waist) lift up arms, put arms to the side, lean forward; lay down and one arm
behind head check breast and breast tissue underarm; patient scoot down table and feet in stirrups, general check of
genitalia, visualize cervix, check ovaries and uterus

Genital/ rectal: general visualization of genitalia, check size of scrotum and penis, hernia exam; ask for position for rectal
exam, visualize anus, 360 sweep, check prostate