Yes No
Full time
Part time
Retired
Are you employed?
If yes:
Have you had any of the following immunizations? If yes, include last year you had the immunization.
Year
Year
Year
Year
Tetanus
Flu Shot
Pneumococcal
Hepatitis B
Have you had any of the following tests? If yes, include last year you had the test.
Year
Year
Year
Year
EKG
Stress Test
Colonoscopy
Mammogram
Check any symptoms and or conditions listed below that you have experienced in the past 12 months:
Change in far vision Change in near vision Blurred Vision
Vision:
Ear pain Loss of Hearing Ringing in Ears
Hearing:
Joint Pain Joint Stiffness Muscle weakness Unsteady Walking
Musculoskeletal
Chest pain Palpitations
Cardiovascular
Shortness of breath Wheezing Coughing Coughing up blood
Respiratory:
Swelling of the Hands/Feet Leg Cramps with walking
Circulatory:
Excessive thirst Frequent urination Unintentional Weight Change > 5 lb.
Endocrine:
Diarrhea Constipation Blood in stools Heartburn
Gastrointestinal
Headaches Numbness or tingling in extremities
Neurological
Depression Anxiety
Emotional:
I attest that this information is correct to the best of my knowledge.
______________________________
X
________
Patient Signature
Date
X ______________________________
________
Reviewed by Clinician’s Signature
Date