ANNUAL PHYSICAL FORM
This form to be used for Annual Physicals Only
Client: _______________________________________
Appointment Date: _______________________
Doctor/Location: _______________________________
Appointment Time: _______________________
Primary Diagnosis: ______________________________
_______________________________________
Date of Birth: _____________________ ______
Staff Attending Appt: _____________________
Diet: _________________________________________
Allergies: _______________________________
Current Medications (including topical and PRN medications):
Medication/Treatment
Dose/Frequency/Route
Reason for Use
Current concerns: __________________________________________________________________________________
_________________________________________________________________________________________________
*Above to be completed by Zumbro House staff*
*Below to be completed by the Physician or Health Care Professional*
Temp: ______ Pulse: ______ Blood Pressure: ____________
Height: ___________
General Health:








Excellent
Date of Tetanus Booster: _________________
Weight: _____________
Good
Fair
Poor
This person is free from communicable diseases.
Is manual restraint if endangering self or others medically contraindicated?
Is the annual flu vaccine recommended?
May take supervised leaves with medication.
Are alcoholic beverages contraindicated?
This person may administer their own medications.
Zumbro House nurse has permission to make decisions about missed dosages.
MD notified of medication errors at nurse’s discretion.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Summary of examination and lab work completed: _______________________________________________________
__________________________________________________________________________________________________
New Orders: _______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Next Appointment: ___________________________________________
Physician/P.A. Signature: ___________________________________________ Date: ________________________
Physician’s Printed Name: ______________________________________________________
Pharmacy: Bloomington Drug
Phone: 952-884-7528
Fax: 952-884-6366
Standing Orders for Over-the-Counter Medications
Name: _________________________________________
Allergies: ______________________
The following may be given on a PRN (as needed) basis. Medications contraindicated will be noted by the
physician. Equivalent generic or store brands may be used. Follow all instructions as listed. Chart medications
administered on the Medication Sheet. Document the reason for giving the medication and the client's
response to the medication in the Health Progress Notes.
Fever/Pain:
Notify nurse of a temperature above 100°F or of pain not relieved by medication.
Tylenol (Acetaminophen) - 500 mg. 2 tablets every 4 hours as needed for fever or discomfort. Do not crush.
OR
Tylenol Elixir (Acetaminophen) - 2 Tablespoons (30 cc) every 4 hours as needed for fever or discomfort. Do
not exceed 8 tablespoons in 24 hours.
OR
Ibuprofen - 200 mg. 1 -2 tablets every 4hours as needed. Do not exceed 6 tablets in 24 hours.
Cold/Cough:
Notify nurse of a temperature above 100°F or below 97.6°F. Notify nurse if client has been exposed to strep
infection or if client experiences persistent cough, earache, congestion, or skin rash. Notify nurse if client has
chest pain. Inform nurse of any symptom lasting more than 3 days.
Tylenol (Acetaminophen) - 500 mg. 2 tablets every 4 hours as needed for fever or discomfort. Do not crush.
OR
Tylenol Elixir (Acetaminophen) - 2 Tablespoons (30 cc) every 4 hours as needed for fever or discomfort. Do
not exceed 8 tablespoons in 24 hours.
Sudafed PE(Phenylephrine HCl) - 10 mg. 1 tablets every 4 hours as needed for nasal congestion. Do not
exceed 6 tablets in 24 hours.
Robitussin DM (Dextromethorphan and Guaifenesin) - 2 teaspoons (10 cc) every 4 hours as needed for cough.
Do not exceed 6 doses in 24 hours.
Chloraseptic Lozenges - One lozenge as needed for sore throat. Follow package directions.
Constipation:
Notify nurse if client has gone 3 days without having a BM. Notify nurse if client does not have a BM within 24
hours after giving laxative.
Milk of Magnesia - 2 tablespoons at bedtime as needed.
Diarrhea:
Notify Nurse. Avoid dairy products, high fiber foods, and caffeine. Give clear liquids, such as 7-Up, Gatorades,
popsicles, Kool-Aid, or apple juice.
Immodium (Loperamide) - 2 mg. 2 tablets after 1st loose bowel movement, followed by 1 tablet after each
subsequent bowel movement. Do not exceed 4 tablets per day. Do not use for more than 2 days.
Indigestion/Heartburn:
Notify nurse of symptoms unrelieved by medication. Notify nurse of vomiting.
Maalox (Alumina and Magnesium) - 1 Tablespoon (15 cc) every 3-4 hours as needed.
TUMS Regular Strength (Calcium carbonate USP 500mg) - Chew 2 tablets every 3-4 hours as needed. Do not
exceed 15 tablets in 24 hours.
Poisoning:
If client is unconscious, call 911. If client is conscious, call Poison Control immediately. 1-800-222-1222. Follow
their instructions. Notify nurse.
Ipecac - administer only as directed by Poison Control.
Pharmacy: Bloomington Drug Phone: 952-884-7528 Fax: 952-884-6366
Minor Wounds:
Notify nurse if area appears infected, if there is a question about the need for stitches, or if burned area is
blistered.
Bacitracin Ointment - Apply a small amount to would 1-3 times daily as needed. Do not use on deep wounds,
puncture wounds, or burns unless directed by physician.
Mild Sunburn/Insect Bites/Minor Skin Irritation (i.e. Poison Ivy/Oak):
Notify nurse before applying to a rash. Do not apply to blistered, raw, or oozing skin. Discontinue use and
consult physician if burning sensation or rash develops or if condition persists for more than 7 days.
Calamine Lotion - Apply liberally 3-4 times daily as needed. Before each application, clean area with soap and
water and dry thoroughly; shake bottle well.
Rashes/Skin Inflammation:
Notify nurse before use. Consult physician if condition persists for more than 7 days.
1 % Hydrocortisone Cream - Apply 3-4 times daily as needed. Do not apply to an area larger than 10"X10"
unless directed by physician. Avoid contact with eye area and mouth.
Athlete's Foot:
Notify nurse prior to use. Consult physician if condition persists for more than 2 weeks. Ensure that client's feet
are washed and dried well daily. Encourage use of clean, white, cotton socks.
Micatin (Miconazole) - Apply cream sparingly to affected areas, including between toes, twice daily. Massage
in well.
Dandruff:
Notify nurse if there are severe or patchy areas on scalp.
Selsun Blue (Selenium Sulfide) Shampoo - Use 1 -2 times per week as needed for dandruff. Shake well before
use. Apply, lather, rinse, repeat. Rinse well. Avoid getting into eyes.
Dry Skin:
Notify Nurse if areas do not respond to treatment within 5 days or if a rash develops.May use non-medicated
hygiene/grooming products as needed or as directed by nurse.
Chapped Lips/Cold Sores:
Notify Nurse if areas do not respond to treatment within 5 days.
Carmex - apply to lips 2-4 times daily as needed for chapping, fever blisters, or cold sores.
OR
Blistex -- apply to lips 2-4 times daily as needed for chapping, fever blisters, or cold sores.
May use non-medicated hygiene/grooming products as needed or as directed by nurse.
Prevention:
Sunburn - Use sunblock with SPF of 15 or greater. Follow direction on bottle.
Insect Bites - Deep Woods Off! (insect repellent with DEET) Follow package directions.
Other:
Physician’s Signature: _______________________________________ Date: ____________________
Pharmacy: Bloomington Drug
Phone: 952-884-7528
Fax: 952-884-6366