Adult Physical Exam Form

Gathers a patient's medical history, habits, and symptoms ahead of a routine adult physical exam.

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Name

Nombre

Apellido

Birthdate

Date

Have you had any surgery?

Yes No

If yes, please list them all.

Mark if you have any of these conditions currently or in the past.

Do you smoke?

Yes No Former smoker

Do you have any allergies?

Yes No

If yes, please list them all.

How much coffee, tea, or carbonated beverage do you drink daily?

How many beers, mixed drinks, or glasses of wine do you have weekly?

Additional Notes

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