Adult Preventative Visit Questionnaire
(Skip any information that does not apply to you)
Have you had a wellness visit in the last year?
Yes
No
If yes, please list location of visit:
Are we your Primary Care Physician?
Yes
No
If yes, would you like us to send you a postcard reminder when your next wellness visit is due?
Yes
No
What month would you like us to send it?
Last PAP (for ages 25+)
Please list year and location completed.
PAP Results
Normal PAP
Abnormal PAP
HPV results of PAP
Normal
Abnormal
Unknown
Not Tested
Last Mammogram (for ages 40+)
Please list year and location completed.
Mammogram Results
Normal PAP
Abnormal PAP
Last Colonoscopy (for ages 50+)
Please list year and location completed.
Colonoscopy Results
Normal PAP
Abnormal PAP
Would you like STD testing today? (This is recommended yearly).
Yes
No
Are you up to date with dental cleanings and check ups? (This is recommended every 6 months).
Yes
No
Are you up to date with vision screenings? (This is recommended every 1-2 years).
Yes
No
Have you had a skin check with a dermatologist in the last year?
Yes
No
Do you have any concerns with your hearing?
Yes
No
Have you had a tetanus vaccine in the last 10 years?
Yes
No
Submit
Should be Empty: