Need a General Yearly Exam? Fill this out.
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.
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:
Social History:
Past Medical History:
Has a provider told you that you have any of the following?
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
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.
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.
Depression Screening
This is recommended on everyone, at least yearly.
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?
Eye Screening:
Have you seen an eye doctor in the last year?
Finishing up:
We tried to be thorough but we may have missed something. Please leave any other notes you want us to know below.
