Pre-Visit Questionnaire Form - Hilltop Family Physicians Page 2
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2PRE-VISIT QUESTIONNAIRE
Page 2
IMMUNIZATIONS
Tetanus Booster (last 10 years)
Date:
Influenza Vaccine (this year)
Have you had the following vaccines?
Date:
Pneumovax 23 Vaccine (ever)
Check all that apply
Date:
Prevnar 13 Vaccine (ever)
PATIENT HEALTH QUESTIONNAIRE
(please circle your answer)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
NOT AT
SEVERAL
MORE THAN HALF
NEARLY EVERY
ALL
DAYS
THE DAYS
DAY
Feeling down, depressed or hopeless?
0
1
2
3
Little interest or pleasure in doing things?
0
1
2
3
PREVENTATIVE SCREENING
PLEASE BRING YOUR REPORT TO YOUR PROVIDER AT YOUR NEXT VISIT, if possible.
NAME
DATE
WHERE PERFORMED
RESULT
Women’s Wellness – Mammogram (50 – 74 years)
Women’s Wellness – PAP (21 -64 years)
Colonoscopy – (50 – 75 years)
Diabetes Care – HbA1c (annually)
Diabetes Care – Urine testing (annually)
Diabetes Care – Diabetic Eye Exam (annually)
Diabetes Care – Diabetic Foot Exam (each visit)
FALL ASSESSMENT (age 65 and older)
Yes
No
Do you feel unsteady on your feet?
Yes
No
Have you fallen 2 or more times in the last year?
ASPIRIN USE
Yes No
Do you take a daily aspirin?
MEDICATIONS
(including over the counter and supplements)
PLEASE LIST ONLY CHANGES SINCE LAST VISIT
NAME
DOSE
FREQUENCY
Revised 10/18/2016
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