Comprehensive Annual Physical Examination Guidelines

Medical History Components

The American Diabetes Association recommends reviewing previous diagnoses, hospitalizations, and treatments as part of a comprehensive medical history 1
A thorough medical history should include assessment of frequency, cause, and severity of past hospitalizations, according to the American Diabetes Association 1
Family history of diabetes, cancer, and other hereditary conditions in first-degree relatives should be assessed, as recommended by the American Diabetes Association 1
The American Diabetes Association suggests assessing tobacco, alcohol, and substance use as part of a social history 1
Physical activity and sleep behaviors should be evaluated, according to the American Diabetes Association 1
Eating patterns and weight history should be assessed, as recommended by the American Diabetes Association 1
Occupational history and environmental exposures should be evaluated, according to the Ca-A Cancer Journal for Clinicians 4

The American Diabetes Association recommends calculating height, weight, and BMI as part of vital signs assessment 1
Blood pressure determination is recommended by the American Diabetes Association, with a strength of evidence rated as high 1
Visual acuity assessment is recommended by the American Diabetes Association as part of a head, eyes, ears, nose, and throat examination 1
Fundoscopic examination is recommended by the American Diabetes Association, with referral to a specialist if needed 1
The American Diabetes Association suggests assessing heart auscultation for murmurs, gallops, or rubs as part of a cardiovascular system examination 1
Lung auscultation for abnormal breath sounds is recommended by the American Diabetes Association as part of a respiratory system examination 1
Abdominal examination, including inspection, auscultation, and palpation, is recommended by the American Diabetes Association 1
The American Diabetes Association suggests assessing sensory examination as part of a neurological examination, with a strength of evidence rated as moderate 1
Deep tendon reflexes should be evaluated, according to the American Diabetes Association 1
Skin examination, including inspection for suspicious lesions, rashes, or abnormalities, is recommended by the American Diabetes Association 1

The American Diabetes Association recommends complete blood count (CBC) as a core laboratory test, with a strength of evidence rated as high 2
Comprehensive metabolic panel (CMP) is recommended by the American Diabetes Association as a core laboratory test, with a strength of evidence rated as high 2
Lipid profile, including total, LDL, HDL cholesterol, and triglycerides, is recommended by the American Diabetes Association, with a strength of evidence rated as high 1
Hemoglobin A1C is recommended by the American Diabetes Association as a core laboratory test, with a strength of evidence rated as high 1
Urinalysis with albumin-to-creatinine ratio is recommended by the American Diabetes Association as a core laboratory test, with a strength of evidence rated as high 1
Thyroid-stimulating hormone (TSH) is recommended for women and older adults, according to the American Diabetes Association 2
Prostate-specific antigen (PSA) is recommended for men over 50, according to the Ca-A Cancer Journal for Clinicians 4
Vitamin B12 levels are recommended for patients on metformin, according to the American Diabetes Association 1
Serum potassium is recommended for patients on ACE inhibitors, ARBs, or diuretics, according to the American Diabetes Association 1

The American Diabetes Association recommends diet and nutrition guidance as part of lifestyle counseling, with a strength of evidence rated as high 1
Physical activity recommendations are suggested by the American Diabetes Association, with a strength of evidence rated as moderate 1
Tobacco cessation counseling is recommended by the American Diabetes Association, with a strength of evidence rated as high 1
Alcohol and substance use counseling is recommended by the American Diabetes Association, with a strength of evidence rated as moderate 1
Cancer prevention strategies are recommended by the Ca-A Cancer Journal for Clinicians, with a strength of evidence rated as high 4
Cardiovascular disease prevention is recommended by the American Diabetes Association, with a strength of evidence rated as high 1
Diabetes prevention and management are recommended by the American Diabetes Association, with a strength of evidence rated as high 1
Mental health screening for depression, anxiety, and disordered eating is recommended by the American Diabetes Association, with a strength of evidence rated as moderate 1

The American Diabetes Association recommends documenting all active and chronic conditions as part of a problem list, with a strength of evidence rated as high 1
A preventive care plan, including recommended vaccinations and schedule for future screening tests, is suggested by the American Diabetes Association, with a strength of evidence rated as high 1
Referrals to specialists are recommended by the American Diabetes Association, with a strength of evidence rated as moderate 1
Patient education materials should be provided, according to the American Diabetes Association, with a strength of evidence rated as moderate 5