Adult annual physical
Preventive care

Blank documentation outlines. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

INTERVAL HISTORY
Patient concerns and goals for the visit: [ ]
Changes in health, hospital or specialist care since last visit: [ ]
Current medications, supplements and allergies reviewed: [ ]
Family history updates: [ ]

RISK REVIEW
Tobacco, alcohol and substance use as reported: [ ]
Physical activity, diet and sleep as reported: [ ]
Depression screening tool and result if performed: [ ]
Other screening questionnaires and results: [ ]

PREVENTIVE SERVICES
Screenings completed, with dates and sources: [ ]
Screenings due or overdue and decisions made: [ ]
Immunizations reviewed, given today or declined: [ ]

EXAMINATION
Vitals measured today, with units: [ ]
Examination performed and findings: [ ]

ASSESSMENT AND PLAN
Preventive recommendations and patient decisions: [ ]
Problems addressed today, documented separately: [ ]
Orders and referrals: [ ]
Counseling provided: [ ]

FOLLOW-UP
Follow-up timing and purpose: [ ]
Return precautions discussed: [ ]
Patient questions and understanding: [ ]