Patient Health Maintenance
Patient Name:
*
Date:
/
Month
/
Day
Year
Date
Date of Birth:
*
/
Month
/
Day
Year
Date
Age:
Over the past 2 weeks, how often have you been
bothered by any of the following problems?
Little interest or pleasure in doing things
*
Not at all
Several Days
More than half the days
Nearly every day
Feeling down, depressed or hopeless
*
Not at all
Several Days
More than half the days
Nearly every day
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Children and Young Adults
Skip if not applicable
Date of Last Annual Well Check
-
Month
-
Day
Year
Date
Location last done:
Date last done: Chlamydia / Gonorrhea (is sexually active, ages 16-24)
-
Month
-
Day
Year
Date
Location last done: (Chlamydia / Gonorrhea)
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Immunizations
Tetanus / Date last done
-
Month
-
Day
Year
Date
Location where Tetanus shot was administered:
Influenza / Date last done
-
Month
-
Day
Year
Date
Location where Influenza shot was administered:
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Adults
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Annual Physical or Medicare Annual Wellness Check / Date last done:
-
Month
-
Day
Year
Date
Location last done:
Colon cancer screening: ages 50+ / Date last done:
-
Month
-
Day
Year
Date
Location last done:
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Female
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Pap Smear / Date last done:
-
Month
-
Day
Year
Date
Location last done:
What year?
Hysterectomy:
Yes
No
What Year was the Hysterectomy performed:
Was this related to cancer?
Yes
No
Date of last Mammogram performed: ages 40+
-
Month
-
Day
Year
Date
Location where Mammogram was performed:
DEXA scan: ages 65+, earlier if risk factors
-
Month
-
Day
Year
Date
Location where DEXA scan was performed:
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Male
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Date of Prostate-Specific Antigen (PSA) Test:
-
Month
-
Day
Year
Date
Location where PSA scan was performed:
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Diabetic
Are you Diabetic?
Yes
No
Date of eye exam:
-
Month
-
Day
Year
Date
Location where eye exam was performed:
Date of foot exam:
-
Month
-
Day
Year
Date
Location where foot exam was performed:
Date of Microalbumin exam:
-
Month
-
Day
Year
Date
Location where Microalbumin test was performed:
Date of HbA1C exam:
-
Month
-
Day
Year
Date
HbA1C Result:
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Primary Care Provider:
Contact Info:
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