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Medical Physical Exam Form Template

Streamline Your Healthcare Processes with This Form

If you're feeling overwhelmed by the paperwork required for physical exams, you're not alone. This template is designed for healthcare workers seeking a straightforward way to gather essential patient data while ensuring compliance with regulatory standards. It simplifies documentation processes, improves patient data accuracy, and enhances overall efficiency. Plus, this template aligns with WCAG guidelines for accessibility, ensuring usability for all. Check out the live template and simplify your workflow today.

Use this Template (FREE) Live Preview
Full name
Date of birth
If you prefer to self-describe your gender, please specify
Email
Mobile phone
Emergency contact full name
Emergency contact phone
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Insurance provider
Member ID
Reason for visit or concerns
Primary care provider
Please list any other medical conditions
Past surgeries or hospitalizations (with dates if known)
Do you have any of the following conditions? Select all that apply
Please Specify:
Current medications and doses
Please list specific allergens and reactions
Allergies (select all that apply)
No known allergies
Medications
Food
Environmental
Latex
Other
Please Specify:
Tobacco use
Never
Former
Current some days
Current every day
Prefer not to say
Alcohol use frequency
Never
Rarely
Sometimes
Often
Always
Pregnancy status
Pregnant
Planning pregnancy
Not pregnant
Not applicable
Prefer not to say
Height (include units)
Weight (include units)
Blood pressure
Heart rate
Select any current symptoms
General appearance
Normal
Abnormal
Not examined
HEENT (head, eyes, ears, nose, throat)
Normal
Abnormal
Not examined
Cardiovascular
Normal
Abnormal
Not examined
Respiratory
Normal
Abnormal
Not examined
Abdomen
Normal
Abnormal
Not examined
Notes on abnormal findings
Neurological
Normal
Abnormal
Not examined
Are immunizations up to date?
Yes
No
Unsure
Over the past 2 weeks, have you felt little interest or pleasure in doing things?
Yes
No
Have you fallen in the past year?
Yes
No
Assessment / Impression
Plan / Orders
Follow-up recommended
As needed
1 week
2 weeks
1 month
3 months
6 months
12 months
Clinician name
Date completed
Clinician role
Physician
Nurse practitioner
Physician assistant
Nurse
Medical assistant
Other
Please Specify:
I consent to receive medical evaluation and treatment as indicated
Yes
No
Type your full name as signature
Signature date
I acknowledge receipt/review of the Notice of Privacy Practices
Yes
No
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paper art illustration depicting a medical physical exam form template with health-related icons and text elements

When to use this form

This form helps your clinic, occupational health team, or school standardize exams and document findings. Use it for pre-employment screenings, annual checkups, sports clearance, and telehealth visits. The layout captures history, vitals, and exam results so you can make clear, defensible decisions. Pair it with the Fitness for duty form for role-specific clearance, or use the Return to work form after an injury or illness. For staff who wear respirators, attach an N95 Fit-test form to complete your compliance file. You can complete it on a tablet in the room and share a clean summary with the patient or HR the same day.

Must Ask Medical Physical Exam Questions

  1. What is the purpose of today's exam, including any job, school, or sport requirements?

    This defines scope and the clearance language you must provide. It helps you tailor assessments and avoid missing required tests or signatures.

  2. Do you have any chronic conditions, recent illnesses, or surgeries?

    It flags risks and guides what to examine or monitor today. If records are complex, reconcile details with the Medical chart review form.

  3. Which medications and supplements do you take, and what allergies do you have?

    Knowing meds and allergies prevents interactions and adverse events. It also explains vital signs and lab results that drugs may affect.

  4. Do you have symptoms such as chest pain, shortness of breath, dizziness, or fainting with exertion?

    These red flags screen for cardio and pulmonary risk before you clear someone for work or sports. Early detection supports timely referrals or testing.

  5. What physical demands does your work or activity involve (lifting, respirator use, heat, night shifts)?

    Linking findings to actual duties supports sound, defensible decisions. If respirators are required, you can document fit testing in your workflow.

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