Chapel Hill Primary Care Annual Physical Form printable pdf download

Chapel Hill Primary Care Annual Physical Form

Chapel Hill Primary Care

Annual Physical Form

Name: ________________________ DOB: ____________ Cell phone: ________________

You are scheduled for an annual physical. Are there any additional issues you would like to

discuss at your visit if time permits?

________________________________________________________________________

Past Medical History:

Have you had any surgery and/or injuries since your last visit? ____________________

If yes, please describe: ____________________________________________________

Please check any of the following illnesses that you currently have:

_____ Asthma

_____ Breast disease

_____ Cancer

_____ Diabetes

_____ Elevated cholesterol _____ Fibromyalgia

_____ Gallbladder disease

_____ Heart disease

_____ High blood pressure

_____ Migraines

_____ Mitral valve prolapse _____ Thyroid problems

_____ Kidney infections/stones

Have you ever had a bone density scan performed? _______ If so, when? _____________

Have you had a screening colonoscopy? ________ When? ___________ Normal or abnormal?

For women only:

Last menstrual cycle: __________ Last pap: ______________ Normal or abnormal?

Date of last Mammogram: _____________ Normal or abnormal?

Updated social history:

Do you smoke? ________ If yes, how many packs per day? _________

If you are a former smoker, when did you quit? ___________

Do you consume alcohol? ____________ If so, how much and how often? ___________

Do you use any recreational/illicit drugs? ____________

Do you use a seatbelt? ______________

Are you currently sexually active? _____________ Method of birth control: _________

Do you exercise regularly? _____________

Occupation: _________________

Marital status: ( ) single ( ) married ( ) domestic partnership ( ) Separated

( ) Divorced ( ) Widowed

Chapel Hill Primary Care Annual Physical Form