Comprehensive Physical Assessment Form for Adults 18-64
A comprehensive health assessment for adults aged 18-64 should systematically evaluate demographics, medical/family/social history, physical examination findings, mental health status, and preventive care needs, with documentation structured to guide risk stratification and intervention planning.
Demographics and Basic Information
Document the following essential data 1, 2:
- Name, date of birth, gender, race/ethnicity (including birthplace and parents' places of origin)
- Primary language and years in current country
- Education level, occupation, literacy status
- Living situation and level of independence
- Marital status and handedness
- Emergency contact person
- Other pertinent healthcare providers
Medical History
Current and Past Medical Conditions 1, 3, 2
Cardiovascular disease:
- Myocardial infarction (date, age at event)
- Arrhythmia/atrial fibrillation
- Coronary interventions (angioplasty, stent, CABG)
- Pacemaker or valve surgery
- Congestive heart failure
- Angina
- Peripheral arterial disease
Cerebrovascular disease:
- Stroke (hemorrhagic or ischemic, with dates)
- Transient ischemic attack
- Carotid endarterectomy
Metabolic conditions:
- Diabetes mellitus (type, duration, complications)
- Hyperlipidemia
- Hypertension
- Thyroid disorders
- Obesity
Other significant conditions:
- Pulmonary disease (COPD, asthma)
- Kidney disease (chronic kidney disease stage)
- Liver disease (NAFLD, hepatitis)
- Musculoskeletal/neuromuscular disorders
- Autoimmune diseases
- Sleep disorders (obstructive sleep apnea)
- Depression, anxiety, or other mental health conditions
- Cancer history
- Hypercoagulable states (DVT, PE, spontaneous abortion)
- Chronic infections (periodontal disease, bronchitis)
Surgical history:
- All previous surgeries with dates
- Any cognitive difficulties post-surgery
Hospitalizations:
- Frequency, causes, and severity of past hospitalizations
Family History 1, 3
Document in first-degree relatives (parents, siblings, children):
- Diabetes mellitus
- Cardiovascular disease (myocardial infarction, stroke)
- Hypertension
- Hyperlipidemia
- Dementia
- Cancer (specify type)
- Autoimmune disorders
- Other neurological diseases
- Age at death and age at disease onset for each condition
Social History 1, 4, 2
Substance use:
- Tobacco (current/former, pack-years)
- Alcohol (drinks per week, binge drinking)
- Illicit drug use
Lifestyle factors:
- Occupation and work schedule
- Physical activity level and barriers to exercise
- Sleep behaviors and duration
- Diet patterns and barriers to healthy eating
- Environmental exposures (secondhand smoke, pesticides)
Social determinants of health 4, 2:
- Food security
- Housing stability and homelessness risk
- Transportation access
- Financial security
- Community safety
- Social supports and isolation
- Health literacy level
- Access to facilities for physical activity
Reproductive history:
- Menopause status
- Contraceptive use
- Sexual history and activity
Current Medications 1, 3, 2
- All prescription medications (name, dose, frequency)
- Over-the-counter medications
- Nutritional supplements
- Complementary and alternative medicine use
- Medication adherence and rationing behaviors
- Allergies or adverse reactions to medications
Vaccination History 1, 2
- Influenza (annual)
- Pneumococcal (PPSV23, PCV schedules)
- Tetanus/diphtheria/pertussis
- Hepatitis B (especially if <60 years)
- COVID-19
- Other age-appropriate vaccinations
Preventive Care Status 1, 2
- Last dental visit
- Last dilated eye examination
- Last colorectal cancer screening (age ≥45)
- Last cervical cancer screening (women)
- Last mammogram (women ≥40)
- Visits to specialists
Functional and Cognitive Assessment
Subjective symptoms 3:
- Changes in memory or thinking speed
- Mood changes
- Gait problems, balance issues
- Tremor
- Swallowing difficulties
- Urinary incontinence
- General health self-assessment
Functional abilities:
- Instrumental activities of daily living
- Work/school performance
- Ability to engage in self-care
Physical Examination
Vital Signs and Measurements 5, 1, 3, 2
- Height and weight (calculate BMI)
- Blood pressure (bilateral if indicated)
- Orthostatic blood pressure (when indicated: diabetes, autonomic symptoms, falls)
- Heart rate and rhythm
- Waist circumference
- Temperature
Cardiovascular Examination 5
- Pulse rate and regularity
- Auscultation of heart (murmurs, gallops, rubs)
- Inspection and palpation of lower extremities for edema
- Presence and quality of arterial pulses (including pedal pulses)
- Ankle-brachial index if diminished pulses 1, 2
Pulmonary Examination 5
- Auscultation of lungs (wheezes, crackles, diminished breath sounds)
Neurological Examination 3
- Cognitive function screening (when suspicion of impairment)
- Motor movements and strength
- Reflexes (deep tendon reflexes)
- Babinski signs
- Gait assessment (timed gait)
- Balance testing
- Sensory examination (vibration, pinprick, temperature)
Musculoskeletal Examination 5
- Orthopedic status
- Range of motion limitations
- Joint deformities
Skin Examination 1, 2
- Acanthosis nigricans
- Injection or insertion sites (if applicable)
- Lipodystrophy
- Lesions or abnormalities
Head and Neck 1, 2
- Thyroid palpation
- Fundoscopic examination (or refer to eye specialist)
Foot Examination (if diabetic or at risk) 1, 2
- Visual inspection (skin integrity, calluses, deformities, ulcers, toenails)
- Pedal pulses
- Temperature sensation
- Vibration sensation
- 10-g monofilament examination
Sensory Screening 6, 7, 8, 6
- Vision: Visual acuity with current correction, visual fields by confrontation
- Hearing: Subjective assessment or screening
Mental Health Screening 1, 4, 2
Depression screening:
- Two-item screen: "Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?"
- If positive, complete PHQ-9
Additional screening:
- Anxiety symptoms
- Diabetes distress (if diabetic)
- Disordered eating behaviors
- Psychosocial stressors 4
Laboratory Testing
Initial/Annual Testing 1, 2
Metabolic panel:
- Fasting glucose or HbA1c (if diabetes risk factors)
- Lipid profile (total cholesterol, LDL, HDL, triglycerides)
- Liver function tests
- Serum creatinine and estimated GFR
- Serum potassium (if on ACE inhibitors, ARBs, or diuretics)
- Complete blood count with platelets
Urinalysis:
- Spot urinary albumin-to-creatinine ratio (if diabetic or hypertensive)
Additional testing based on conditions:
- Thyroid-stimulating hormone (if symptoms or type 1 diabetes)
- Vitamin B12 (if on metformin)
- Hemoglobin A1c (if diabetic, every 3 months)
Cardiac Testing (if indicated) 5
- Resting 12-lead ECG
- Cardiac echocardiogram (if cardiovascular disease)
Other Diagnostic Studies (if indicated) 3
- Carotid ultrasound
- Brain MRI
- C-reactive protein
- Homocysteine
- Insulin level
- Clotting factors, fibrinogen
Quality of Life Assessment 5
- Patient's perceived health-related quality of life
- Health status assessment
- Patient's self-assessment of visual status and needs 6, 7, 6
Technology and Self-Management 1, 2
- Use of health apps, online education, patient portals
- Glucose monitoring devices (if diabetic)
- Connected medical devices
Assessment and Treatment Plan Documentation 5
Document:
- Current health status summary
- Priority short-term goals (weeks to months)
- Intervention strategies for risk reduction
- Patient treatment plan
- Discharge/follow-up plan
- Communication plan with patient and family
- Coordination with primary care provider and specialists
Common Pitfalls to Avoid:
The most critical error is conducting a superficial review-of-systems checklist without exploring positive findings. When patients endorse cardiovascular symptoms, probe for specific anginal equivalents, exertional limitations, and orthopnea. For social history, don't simply document "denies tobacco/alcohol"; quantify pack-years for former smokers and drinks per week for current drinkers, as these have direct implications for cardiovascular and cancer risk 4.
Another pitfall is neglecting social determinants of health 4, 2. A patient's inability to afford medications, lack of transportation to appointments, or food insecurity directly impacts outcomes and must be documented to guide realistic intervention planning.
Finally, avoid deferring mental health screening because "the patient seems fine." Depression and anxiety are highly prevalent, often unrecognized, and significantly impact chronic disease management and quality of life 1, 2. The two-question screen takes less than 30 seconds and has high sensitivity.
This structured approach ensures comprehensive evaluation while maintaining efficiency through systematic documentation that guides risk stratification and evidence-based intervention planning 1, 2.