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REFERRAL SOURCE - We ask patients how they found our practice to enhance our services and outreach. Please share how you discovered us.
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If Other, please specify
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Pharmacy Name
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Pharmacy Address or Pharmacy Phone Number
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PATIENT DEMOGRAPHICS
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Are you of Hispanic or Latino/a origin?
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Which race or ethnicity best describes you?
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MARITAL STATUS Please select your current marital status.
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RELIGION Please select the option that best represents your personal religious beliefs.
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PRIMARY LANGUAGE What is your primary language spoken?
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EMPLOYMENT STATUS What is your current employment status?
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OCCUPATION Please select your occupation.
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INCOME What is your estimated annual household income?
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EDUCATION What is your highest level of education completed?
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HEALTH HISTORY
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VISIT REASON What are your primary health concerns or goals for this visit?
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CURRENT MEDICATION Which medications are you currently taking? If none, enter N/A. {Medication | Dose | Frequency | Effective?}
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MEDICAL HISTORY List any current or past health conditions (select all that apply).
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If Other, please specify
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ALLERGIES Do you have any allergies (including medication, substance, food, or environmental)?
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If YES, please specify
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SURGICAL & HOSPITALIZATION HISTORY Have you ever had any major surgeries, procedures, hospitalization, or ER visits?
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If YES, list the MM/YR and reason(s):
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FAMILY HISTORY
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Mother
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If Other, please specify
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Father
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If Other, please specify
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Sister
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If Other, please specify
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Brother
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If Other, please specify
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SOCIAL HISTORY Tell us about your lifestyle and personal habits.
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How often do you drink alcohol?
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How often do you smoke cigarettes or use other tobacco products?
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How often do you use vape or e-cigarette?
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How often do you use marijuana or recreational substances?
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VITAL SIGNS Enter latest data for patient, if known.
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HEIGHT
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WEIGHT
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TEMPERATURE
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HEART RATE
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BLOOD PRESSURE
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FASTING BLOOD SUGAR
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WOMEN'S HEALTH
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Are you currently pregnant or breastfeeding?
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When was your last menstrual period? If uncertain, list an approximate date.
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Are your menstrual periods regular, occurring once every 25-28 days?
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Are your menstrual periods heavy (ie, require double protection, soiling clothes, or clots larger than a quarter)?
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If no, briefly provide details
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I. Wellness Screening
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1. Describe your diet.
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2. Any broken bones or injuries within the past year?
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3. How often do you exercise?
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4. In the past two weeks, how was your energy level?
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5. Any history of mood disorders (such as depression or anxiety)?
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6. Any problems with sleeping (such as snoring, trouble falling asleep, or trouble staying asleep)? Select all that apply.
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7. Any trouble with hearing?
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8. Have you ever been prescribed glasses or contact?
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9. Have you fallen or had any trouble walking in the past year? Select all that apply.
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10. Do you have any ongoing memory problems?
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11. Do you have advanced directive or living will?
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12. SEXUAL HEALTH If you are currently age 15 or above and have ever been sexually active, have you been screened for sexually transmitted infections (STIs) in the past year?
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If yes, list the MM/YR:
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13. COLON CANCER SCREENING If you are age 45 or above, have you ever been screened for colon cancer?
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If yes, list the MM/YR:
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14. LUNG CANCER SCREENING If you are age 50 or above and have ever smoked, have you had lung imaging (ie, X-Ray or CT) in the past year?
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If yes, list the MM/YR:
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15. WOMEN'S HEALTH If you are currently age 50 or above, have you ever been screened for osteoporosis?
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If yes, list the MM/YR:
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16. WOMEN'S HEALTH If you are currently age 35 or above, have you had a mammogram within the past year?
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If yes, list the MM/YR:
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17. WOMEN'S HEALTH If you are currently age 21 or above, have you had a cervical cancer screening or "pap exam" in the past year?
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If yes, list the MM/YR:
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18. MEN’S HEALTH If you are currently age 40 or above, have you ever been screened for prostate cancer?
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If yes, list the MM/YR:
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II. Patient Health Questionnaire - 9 (PHQ-9)
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Instructions: How often have you been bothered by any of the following problems during the PAST 2 WEEKS?
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1. Little interest or pleasure in doing things
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2. Feeling down, depressed, irritable, or hopeless
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3. Trouble falling asleep, staying asleep, or sleeping too much
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4. Feeling tired, or having little energy
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5. Poor appetite, weight loss, or overeating
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6. Feeling bad about yourself — or feeling that you are a failure, or that you have let yourself or your family down
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7. Trouble concentrating on things like school work, reading, or watching TV
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8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you were moving around a lot more than usual
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9. Thoughts that you would be better off dead, or of hurting yourself
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III. General Anxiety Disorder-7 (GAD-7)
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Instructions: Over the LAST TWO WEEKS, how often have you been bothered by the following problems?
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1. Feeling nervous, anxious, or on edge
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2. Not being able to stop or control worrying
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3. Worrying too much about different things
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4. Trouble relaxing
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5. Being so restless that it is hard to sit still
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6. Becoming easily annoyed or irritable
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7. Feeling afraid, as if something awful might happen
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