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What kinds of information are on physical examination forms?

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Quick Answer

The information on a physical exam form includes a medical history, vital signs, an evaluation of the patient's physical appearance, an assessment of the internal organs and any lab testing requested by the physician, according to WebMD. Depending on the sex of the patient, other tests may be performed.

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Full Answer

The history of the patient gives the physician knowledge of the patient's lifestyle behaviors, such as smoking, sexual health and diet. History is also used to determine whether the patient's vaccinations are current and if there is a family history of serious disease, such as diabetes, as WebMD explains.

Vital signs are collected during a physical exam, and they are recorded in the patient's medical records. Blood pressure, respiration rate, heart rate and body temperature are recorded on the chart for further reference by the physician. According to WebMD, abnormal readings may indicate existing diseases.

The physician evaluates the physical appearance of the patient by gathering information based on walking, standing and other physical indicators. Looking at the patient's skin and nails is a good indicator of a problem in others areas of the body, according to WebMD.

Using a stethoscope to observe internal organs, the physician gathers data about the heart, lungs and digestive organs. Listening to the heart indicates whether the patient has an irregular heartbeat, a heart murmur or other heart disease, as WebMD explains. Abnormal sounds from the lungs, such as wheezing and crackling, can indicate lung disease or other pulmonary issues.

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