What Types of Information Are on a Basic Physical Examination Form?


Quick Answer

Information on a basic physical examination form includes the patient's medical history, vital signs, general appearance, heart exam results and lung exam results, according to WebMD. The physical examination form also includes information about head and neck exams, neurological exams, abdominal exams, dermatological exams and exams of the patient's extremities.

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What Types of Information Are on a Basic Physical Examination Form?
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Full Answer

In the history section, the doctor asks about the patient's lifestyle behaviors, such as alcohol use, smoking, diet and exercise, states WebMD. The doctor also updates the patient's personal and family history.

In the vital sign section, the doctor indicates the patient's heart rate, temperature, blood pressure and respiration rate, as WebMD indicates. On the general appearance section, the doctor includes information about the patient's memory and quickness.

The physician uses a stethoscope to listen to the heart and lungs to fill out the heart exam and lung exam sections. In the head and neck exam, the doctor checks the tonsils, throat, teeth and gums. The doctor checks the nerves, muscles and reflexes in the neurological exams and the skin and nails in the dermatological exams. The abdominal exam checks the liver's size and for abdominal fluid, while the extremities exam checks for sensory changes in joints, arms and legs.

Some details in the basic physical examination are different for males and females, according to WebMD. Males go through testicular exams, hernia exams, penis exams and prostate exams. Females undergo breast exams and pelvic exams. Basic forms also include lab information concerning urinalysis, chemistry panels and complete blood counts.

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