Annual Exam FormAnnual Exam Section 1Who is your Physician?*Bart Price, MDPetra Travnicek, MD, FACPPatient Name*Your Email Address* Date* MM slash DD slash YYYY DOB* MM slash DD slash YYYY Please list any major symptoms you are having with your health, new medical problems you have been diagnosed with in the PAST YEAR, or any new concerns you have:Have you had surgeries in the past year? Yes NoSurgeriesSurgeriesSurgeryDate of SurgerySurgeon’s Name Current Medications / Vitamins / Supplements / HerbsCurrent Medications / Vitamins / Supplements / Herbs*Name of MedicationStrengthFrequency Click "+" to list more medicationsAllergiesPlease list any NEW allergies and the reactions:*Review of Body SystemsConstitutional Fever Fatique Third Choice Abnormal Sweating Weakness Change in Weight Change in Appetite Difficulty Sleeping Intolerance to Heat or ColdHead Headache Dizzy Faint SeizuresEyes Loss of vision Floaters Eye painEars Noise in ears Hearing loss Ear painNose Congestion Change in smell Loss of smellBreasts Pain Lumps Nipple changes or dischargeRespiratory Cough Shortness of breath Wheezing Change in sputumCardiovascular Chest pain Palpitations Irregular heartbeats Varicose veins Pain in calf with walkingGastrointestinal Nausea Vomiting Difficulty swallowing Indigestion Abdominal pain Burping BloatingIntestinal Pain Constipation Diarrhea Excessive flatulence Hemorrhoids Rectal pain Rectal bleeding Change in stoolUrinary Increased frequency Change in stream Pain with urination Urgency Incontinence Loss of urine when coughing or sneezing Getting up at night to urinateGetting up at night to urinate - How many times?Musculoskelatol Painful joints Swollen joints Arthritic changes Tendons Gout Foot problems Muscle pain or weaknessList jointsMen Changes in libido Premature ejaculation Erectile dysfunctionWomen Painful menstruation Change in periods Painful intercourse Vaginal discharge Vaginal dryness or irritation Changes in libidoSkin Rashes Itching Acne Persistent sores Skin cancers Hair loss Seborrhea PsoriasisHematology Bruising Swollen glandsConsumptionTobacco: Do you smoke?*YesNoDid you quit or cut back on smoking?YesNoDo you drink alcohol?*YesNoAlcohol - ounces per DayAlcohol - ounces per WeekAlcohol - ounces per MonthHow many cups of caffeineted beverages per day (coffee, tea & soda)*Exercise HabitsExcercise*Type of ExerciseFrequency Other types of physical activity:Goals for exercise this year:How will you achieve these goals:Completed byDate MM slash DD slash YYYY SignatureReset signature Signature locked. Reset to sign again
