Name
*
First Name
Last Name
Email
*
Date of Birth
*
Needed for identification purposes--we have a lot of "same names"
MM
DD
YYYY
Indicate your main health concerns
*
Annual physical
Other--list below
If reason for visit is "Other"
Detail concerns, e.g. high blood pressure.
Medication Allergies
Please list any medications that you are allergic to or don't tolerate. Please describe the reaction, if known.
Current Medications, Vitamins and Supplements
Please include all prescription medications, over the counter medications, vitamin supplements, and herbal supplements that you currently take, along with the dosage, frequency taken and prescriber's name, if the recommendation was made by a different doctor.
Do you use medication prescribed for another person?
No
Yes
How often do you use products containing nicotine?
Never
Less than once per year
Less than once per month
Less than once per week
Most days per week
Daily
Have you ever used nicotine cigarettes in the past?
No, never
Yes, but only once
Yes, fewer than 100 cigarettes
Yes, more than 100 cigarettes
If you have smoked more than 5 packs of cigarettes over your lifetime, when did you smoke the last cigarette?
How often do you use products containing THC/CBD?
Never
Less than once yearly
Less than once monthly
Less than once weekly
More than once weekly
Daily
More than once daily
How often do you use other recreational substances?
Never
Less than once yearly
Less than once monthly
Less than once weekly
More than once weekly
Daily
More than once daily
What do you do for exercise?
E.g.: walking 30 minutes daily, swimming once a month, spin class 3 times a week.
Describe your eating habits.
What does a typical food day look like for you? What do you snack on? Any dietary restrictions? Intermittently fasting?
Have you ever been diagnosed with an eating disorder?
No
No, but I have concerns
Yes, but I have not received treatment
Yes, and I have received treatment
If you are working, what kind of work do you do?
Computer based? Sedentary? Occupational exposures?
Are there guns in your home?
No
Yes
What are your hobbies/interests?
Do you wear a seatbelt while driving or riding in a vehicle?
Always
Sometimes
Never
I never travel via any motorized vehicle
Do you wear a helmet while using a motorcycle, bicycle, scooter, skateboard or rollerskates/rollerblades?
Always
Sometimes
Never
I never use bicycles, scooters, or any skating paraphernalia
Do you have pets?
No
Yes
I have received the following vaccines
When was your last tetanus booster?
Either Td or TDAP, whichever was most recent.
MM
DD
YYYY
Have you received colon cancer screening in the past?
Which of the following have you had? (Select all which apply)
Date of most recent colorectal cancer screening
MM
DD
YYYY
I have received breast cancer screening
Select all which apply within the past year.
Date of most recent breast cancer screening
MM
DD
YYYY
I have received bone mineral density testing (DEXA)
No
Yes
Date of most recent bone mineral density test
MM
DD
YYYY
Surgeries and Procedures since last physicial
Please give date, area of body, name of procedure, name of doctor and any test results if known.
Family History Update
Please note major health concerns of your grandparents, parents, siblings and/ or children which have been discovered since your last physical.
Where else have you received care in the past year?
Select all which apply. Note details below.
Other Care Notes
Please give date, area of body, name of procedure, name of doctor and any test results if known.
Review of Systems
General
Skin
Head, Ears, Eyes, Nose, Throat
Nodes and Glands
Breasts
Lungs
Cardiovascular
Gastrointestinal
Musculoskeletal
Psychological
Neurological
Urinary
Gynecologic
Select all that apply
When was your last regular menstrual cycle?
Please enter the first day of your last period. Feel free to enter the year only if it has been over 12 months since your last period.
MM
DD
YYYY
How long do your periods last?
I do not have periods
Less than 3 days
Four to eight days
Nine to thirteen days
Fourteen days or longer
Obstetric
Please select all which apply
Are you currently pregnant?
No
Yes
Are you currently breastfeeding?
No
Yes
Total number of pregnancies
0
1
2
3
4
5
6
7
8
9
Total number of live births
0
1
2
3
4
5
6
7
8
9
Total number of miscarriages
0
1
2
3
4
5
6
7
8
9
Total number of elective pregnancy termination(s)
0
1
2
3
4
5
6
7
8
9
Sexual
Please select all answers with which you identify
Additional details:
How do you identify your gender?
What is your sexual orientation?
Please note anything we have not given the opportunity to update.
Tell us how much you enjoy filling in forms.
