FEMALE PHYSICAL FORM
NAME __________________________________ BIRTH DATE _________________ DATE ____________
VITAL SIGNS: Wt________ Ht ________ Temp ________ Pulse ________ Resp ________ BP ________
1. Reason for office visit? _______________________________________________________________
_____________________________________________________________________________________
2. Lifestyle/Social History:
A. Tobacco use: No / Yes;
Type & Amount per day _________
B. Caffeine: No / Yes; Type & Amount per day _________
C. Alcohol: Type & Amount per week: ________ Drugs: Type & Amount per week: _________
D. Diet: Meals per day _____; Servings of high calcium food per day ___________
E. Exercise: No / Yes; Type & Amount per week __________
F. Sexual History: Number of sexual partners in the past year _____; Lifetime __________
G. Seat belt use: Yes / No Smoke alarm in home: Yes / No Guns in home: Yes / No
H. Occupation(s) and any health risk: _______________________________
I. Home: Do you feel safe in your home? Yes / No
If married, how would you rate your marriage? ________: # of children ________
3. Review of systems (significant symptoms since last HMV):
A. General – fever, weight loss, weight gain, fatigue, loss of appetite, pain
B. Skin – rash, new mole or change in mole.
C. Eyes – blurred vision, double vision, and redness. Date of last eye exam: __________
D. ENT – hearing loss, sinus pain, difficult swallowing, and hoarseness. Date of last dental visit_________
E. Allergy – sneezing, itching or watering eyes
F. Respiratory – cough, wheeze, sputum
G. Cardiovascular – chest pain, shortness of breath, palpitations, swelling in feet, high cholesterol
H. GI – nausea, vomiting, diarrhea, constipation, blood in stool, abdominal pain
I. GU – Date last period __________; Periods every _____ day for _____ days;
Family planning type: ______; Date last Pap ________; problems with periods, hot flashes,
abnormal pap, PMS, vagina discharge or dryness, pelvic pain, history of or concern for STD,
pain with urination, frequent urination, blood in urine; # of pregnancies _____ # of live births _____
J. Breast – lump, pain, nipple discharge. Date of last mammogram __________
K. Endocrine – excess thirst, urination or appetite; heat or cold intolerance, fatigue, nervousness.
L. Blood/Immune System – easy bruising or bleeding, anemia, recurrent infections
M. Musculoskeletal – joint pain, swelling, loss of motion, difficulty w/daily activities
N. Neurological – headache, numbness, weakness, dizziness, speech problems
O. Psych – stress, depression, sleep disturbance, trouble in your home.
4. Immunizations (dates): Tetanus __________ Flu __________ Pneumovax __________
5. Do you have an advanced directive or living will? Yes / No
6. Current medications, including over the counter products: See problem sheet. Yes / No
7. Medication Allergies / Side Effects:
8. Hospitalizations & Surgeries (Month/Year/Problem). See problem sheet, Yes / No
9. Family History. See problem sheet, Yes / No
10. PHYSICAL EXAMINATION
A. GENERAL APPEARANCE: patient appears stated age, no distress.
B. SKIN: No abnormal moles, rashes or sores.
C. HEAD: Is a traumatic
D. EYES: Pupils equal & reactive; nonicteric.
E. ENT: External ears, tympanic membranes, and canals appear normal. External nose and nasal mucosa
appears normal. Lips, teeth, gums, oropharynx normal.
F. NECK: No abnormal mass or tenderness. Thyroid is normal.
G. NODES: No adenopathy neck, supraclavicular or inguinal areas.
H. BREASTS/AXILLA: Normal on inspection and palpation.
I. LUNGS: No wheezes, rales, and rhonchi. No dullness to percussion.
J. CVS: Regular without gallop or murmur. Carotid pulses normal; no bruit.
K. ABDOMEN: No abnormal mass, tenderness, hepatosplenomegaly. No bruit.
L. EXTREMITIES: No edema. Pedal pulses normal.
M. MUSCULOSKELETAL EXAM: No evidence of arthritis in large/small joints. Good range of motion.
N. NEUROLOGIC: Cranial nerves are symmetric. Motor exam is symmetric.
O. PSYCH: Judgment & insight are good. Oriented to time, place, person.
Short and long term memory is normal. Mood and affect are normal.
P. PELVIC: External genitalia are normal without any lesions. Vagina is normal without lesions or
discharge. Urethra shows no mass, tenderness or discharge. Cervix appears normal without lesion or
discharge. Pap smear was obtained. Bimanual exam shows the uterus is normal in size, smooth,
mobile and nontender. Adnexa are normal in size and non tender.
Rectal-vaginal exam is normal without mass or tenderness and confirms bimanual exam.
STD Screening (GC / Chlamydia) Yes _____ No _____
11. A/ P
12. HEATH PROMOTION/DISEASE PREVENTION
A. Discussed healthy diet, multivitamin and exercise.
B. Blood work: lipids _____, glucose _____, other __________
C. Family planning methods discussed.
D. Discussed self breast exam. Mammogram recommended for ____________________
E. Colon cancer screening
F. Calcium intake reviewed.
G. DEXA for screening or F/U? _____________________________
(>65 or w/risk-fracture, FH, estrogen defic, Tob / EtOH, steroid)
H. Hormone replacement therapy risk/benefits reviewed.
I. Immunizations recommended: ________________________________
J. Discussed Living Will/Durable Power of Attorney
K. Health Screening Log reviewed / completed.
L. Past medical history / chronic problem sheet reviewed/updated
M. Return to our office: _______________