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Need a General Yearly Exam? Fill this out. 

Gender at birth Required

Chief Complaint:

Are you having any issues that are concerning you right now? How are you feeling? Anything you think I should know about you?

Review of Systems:

We know it is a lot of questions, but they really are important! Please read through them and check what is applicable to you.

General Required
Cardiac Required
Neurological Required
ENT Required
Muscle/Joints Required
Pulmonary Required
Circulatory Required
Genitourinary Required

Tell me about it: 

If you clicked yes on anything above, please explain. 

Medications:

What medicines are you on? Yes, supplements count. Please also list your current skincare regime.

Allergies:

Medication Allergies Required
Food Allergies or intolerances Required
Are you allergic to latex? Required

Social History:

Have you ever smoked? Required
Do you drink alcohol? Required
Have you ever felt you should cut down on your drinking? Required
Have people annoyed you by criticizing your drinking? Required
Have you ever felt bad or guilty about your drinking? Required
Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? Required

Past Medical History:

Has a provider told you that you have any of the following?

Diagnosis
Diagnosis

Past Family History

Tell us about your family. Common diagnoses include: High blood pressure, Migraines, Stroke, Thyroid dysfunction, Heart attack, Valvular heart disease, Cancer, COPD, Tuberculosis, Asthma, Arthritis, Depression, Anxiety, Hepatitis and High cholesterol
 

Living or Deceased? Required
Living or Deceased? Required
Living or Deceased? Required
Living or Deceased? Required
Living or Deceased? Required
Living or Deceased? Required

Surgeries:

Tell me about any surgeries, even if they were a long time ago. Please include the year you had it and as many details as possible. 

Hospitalizations:

Have you ever stayed the night in the hospital? Why? What year?

Injuries:

Have you ever injured yourself? How? What year?

Vaccinations:

Add the year you last received this vaccine, please list all you can remember.

Recommended Screenings:

The following are recommended for the best health possible. We'll tell you how often they should be done, you tell us when you had your last one done. 

Female Screenings
Female Screenings
Female Screenings

Colon Screenings:

Colon Screening - You usually only need to do one type of screening. So if you have dreaded the colonoscopy, there are other options! Start screening at age 45.

Colon Screening

Depression Screening

This is recommended on everyone, at least yearly.

Little interest or pleasure in doing things Required
Feeling down, depressed or hopeless Required

Anxiety Screening:

This is recommended on everyone, at least yearly.

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious, on edge Required
Not being able to stop or control worrying Required
Worrying too much about different things? Required
Trouble relaxing Required
Being so restless it's hard to sit still. Required
Becoming easily annoyed or irratable Required
Feeling afraid, as if something awful might happen. Required

Eye Screening:

Have you seen an eye doctor in the last year?

Eye Screening Required

Finishing up:

We tried to be thorough but we may have missed something. Please leave any other notes you want us to know below.

Thanks for submitting!

© 2023 by Crafted Sustainable Wellness

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