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Adult Physical Exam Form Template

Streamline Your Adult Physical Exams with Our Template

Conducting thorough physical exams can be a daunting task without the right tools. Our Adult Physical Exam Form Template is designed for healthcare professionals looking to streamline their examination process and ensure comprehensive patient assessments. This template helps you collect essential health information effortlessly, increase patient compliance, enhance documentation accuracy, and save valuable time during appointments. Plus, it's customizable to fit your needs, making it ideal for any practice. Explore the template now to simplify your exam workflows.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Email
Mobile phone
Home address
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Emergency contact full name
Emergency contact phone
Emergency contact relationship
Spouse/Partner
Parent
Child
Sibling
Relative
Friend
Caregiver
Other
Please Specify:
Insurance provider
Member ID
Reason for today's visit
Current symptoms (select all that apply)
How long have your current symptoms been present?
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Not applicable
Pain level today
None
Mild
Moderate
Severe
Past surgeries or hospitalizations (include dates if known)
Current medications and supplements (name, dose, frequency)
Ongoing medical conditions (select all that apply)
Allergies (medications, foods, latex, or other) and reactions
Family history of significant conditions (select all that apply)
Nicotine use (cigarettes, vaping, smokeless)
Never
Former
Current some days
Current every day
Alcohol use
Never
Monthly or less
2-4 times per month
2-3 times per week
4 or more times per week
Prefer not to say
Exercise frequency
Never
Rarely
Sometimes
Often
Always
Pregnancy status (if applicable)
Yes
No
Not applicable
Prefer not to say
Do you use any non-prescribed recreational drugs?
Never
Past use
Occasional use
Regular use
Prefer not to say
Over the past 2 weeks, how often have you felt down, depressed, or hopeless?
Very rarely
Rarely
Sometimes
Often
Very often
Over the past 2 weeks, how often have you had little interest or pleasure in doing things?
Very rarely
Rarely
Sometimes
Often
Very often
Height (please include units, e.g., cm or ft/in)
Weight (please include units, e.g., kg or lb)
I consent to receive medical evaluation and treatment today.
Yes
No
I acknowledge receipt or availability of the Notice of Privacy Practices (HIPAA).
Yes
No
Printed name of patient/guardian
Date signed
I understand I am financially responsible for charges not covered by insurance.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration depicting an adult physical exam form for a healthcare article.

When to use this form

Use this form to document a complete checkup for new patients, annual wellness visits, pre-employment screenings, or return-to-work reviews. It helps you capture vitals, history, meds, allergies, lifestyle, and risk factors in one place so you can make clear next steps. Clinicians, occupational health teams, and HR managers benefit when they need reliable records and a fast go/no-go decision. For third-party submission, pair results with the Medical examination report form. When participation or travel depends on health status, add a Medical clearance form. If infectious risk is part of the assessment, include a TB Screening form. The outcome: clean documentation, fewer follow-ups, and faster clearance or referrals.

Must Ask Adult Physical Exam Questions

  1. What medications and supplements do you take, including doses and frequency?

    This prevents interactions and guides safe prescribing, vaccines, and anesthesia choices. Accurate details also speed prior authorizations and reduce call-backs.

  2. Do you have any chronic conditions or prior surgeries and hospitalizations?

    These shape your risk for heart, lung, endocrine, and bleeding issues. Knowing dates and treatments helps plan monitoring and referrals.

  3. What allergies or adverse reactions have you had to medicines, foods, latex, or vaccines?

    Documenting allergens and reactions protects you from serious events during exams, labs, or procedures. It also informs vaccine selection and emergency planning.

  4. What is your job role and typical activity level on and off work?

    This links your health to real tasks and helps tailor restrictions or training. For workplace decisions, pair findings with the Fitness for duty form to support objective clearance.

  5. Have you had recent symptoms such as chest pain, shortness of breath, fainting, fever, or unexplained weight change?

    Acute or red-flag symptoms trigger timely diagnostics and may delay clearance until stable. Early identification reduces liability and improves outcomes.

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