Annual Physical Examination Form Completion Guide
This Annual Physical Examination Form is essential for gathering comprehensive health information. It is designed for individuals with intellectual and developmental disabilities, ensuring their health needs are documented and addressed. Proper completion of this form helps facilitate effective communication between healthcare providers and patients.
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How do I fill this out?
Begin by entering your personal details in the designated fields at the top of the form. Next, provide information regarding any current medications and allergies. Finally, complete the evaluation of your health by filling out the sections regarding physical examination findings and other relevant medical history.
How to fill out the Annual Physical Examination Form Completion Guide?
1
Enter personal details including name, date of birth, and address.
2
List current medications, doses, and frequency of intake.
3
Provide immunization history and tuberculosis screening results.
4
Record any hospitalizations or surgical procedures.
5
Complete the general physical examination section.
Who needs the Annual Physical Examination Form Completion Guide?
1
Individuals receiving health care services related to I/DD.
2
Caregivers and family members managing patient care.
3
Medical professionals conducting annual health assessments.
4
Providers of residential services for individuals with I/DD.
5
Mental health directors requiring comprehensive health data.
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What are the instructions for submitting this form?
To submit the Annual Physical Examination Form, please fax it to (215) 790-4976 or send it via email to healthdocs@pchc.org. You can also submit a physical copy directly to the Philadelphia Coordinated Health Care office located at 123 S. Broad Street, 22nd Floor, Philadelphia, PA 19109. Be sure to retain a copy for your records and follow up with your healthcare provider to ensure receipt.
What are the important dates for this form in 2024 and 2025?
For the Annual Physical Examination Form, ensure it is submitted by the designated deadlines set by your healthcare provider. Keep in mind that annual examinations are typically due around the same date each year, so plan accordingly. Review any updates for procedural changes every year.
What is the purpose of this form?
The purpose of the Annual Physical Examination Form is to ensure that individuals receive comprehensive and consistent health checkups. It collects crucial medical history, medication information, and physical examination findings relevant to the patient's health status. By systematically gathering this data, healthcare providers can better tailor treatments and assessments to meet the unique needs of patients with intellectual and developmental disabilities.
Tell me about this form and its components and fields line-by-line.
- 1. Name: The full name of the individual undergoing the examination.
- 2. Date of Exam: The specific date the examination is taking place.
- 3. SSN: The Social Security Number for identification.
- 4. Date of Birth: The birth date of the individual.
- 5. Sex: The gender of the individual.
- 6. Current Medications: List of medications currently taken by the patient.
- 7. Allergies/Sensitivities: Any known allergies or sensitivities of the patient.
- 8. Immunization History: Documentation of vaccines received by the individual.
- 9. Physical Examination Findings: Results from the physical exam, including vital signs and evaluations.
- 10. Hospitalizations/Surgical Procedures: History of hospital stays or surgeries.
What happens if I fail to submit this form?
Failing to submit this form may lead to lapses in necessary health care assessments. Consequently, important health information could be missed, potentially affecting treatment plans. Ensure timely submission to avoid any disruptions in patient care.
- Lack of Medical Updates: Without submission, healthcare providers may not receive critical updates on the patient's health status.
- Delayed Treatments: Late or missing forms can result in delays in receiving needed treatments or interventions.
- Increased Risk: A failure to maintain current health records can increase risks associated with untreated health conditions.
How do I know when to use this form?
- 1. Annual Health Checkup: Required for documenting yearly physical examinations.
- 2. Medication Adjustments: To report any changes in prescribed medications or dosages.
- 3. New Health Conditions: When a new diagnosis or significant change in health arises.
Frequently Asked Questions
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