Patient Information Form

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ID Number: _____________
□
□
□
Sex:
Male
Female
Age:
5-20
□
21-34
□
35-44
□
45-59
□
Diagnosis: ______________________________________________________________________________________________
60+
Physical Health
Baseline
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Date:
Height (inches)
Weight (lbs)
Blood Pressure
Exercise (at least 30
minutes)
Indicate:
X - None
1 - 1-3 times a week
2 - 4-7 times a week
Change in Chronic
Condition: Have there
been changes to dx of
diabetes, high
cholesterol, high BP etc.
Are you on a specialized
diet?
Indicate Y for yes and the
type of diet or N for no.
Number of days ill during
the last quarter that
resulted in missed work
or volunteer activities?

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