Executive Health Physical Examination Form
Personal Information
Name
Date of Birth
Gender
Email
Phone
Company / Organization
Medical History
Do you have any past or current illnesses?
Are you currently taking any medications?
Any history of surgeries or hospitalizations?
Family medical history
Lifestyle
Do you smoke?
Yes
No
Do you consume alcohol?
Yes
No
Physical activity level
Allergies
List any known allergies
Review of Systems
General
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Neurological
Physical Measurements
Height (cm)
Weight (kg)
Blood Pressure (mmHg)
Pulse (bpm)
Physician's Notes
Physician Name
Date