Health Screening Physician Form
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1Health Screening Physician Form
A Health Screening can be a valuable guide in your health journey. This form is designed to help you partner with your
primary physician in establishing a starting point.
Instructions:
•
Complete the top section of the form and sign it.
•
Take this form to your healthcare provider. Together, fill it out with your most recent screening results. (If you haven’t had
these tests done recently, ask your healthcare provider to test them.)
•
Make notes about any numbers that your healthcare provider suggests working on; also ask what your goal should be,
and when to re-test.
•
Submit your form following the instructions at the bottom of this page.
To be completed by you (member): Enter this information to confirm your identity and eligibility.
Employer (Spouses/dependents—list the employer sponsoring your
Last four digits of the Employee’s SSN#
benefits)
First name
Last name
Date of birth
Email
(MM/DD/YYYY)
/
/
Please answer the following questions prior to taking to your physician's office:
1) If you are planning to make any changes listed below in the next six months, please select one or two areas that you will prioritize. For the others, let us
know whether or not you plan to make a change soon—or if you don’t feel a change is needed.
Lose weight?
1st Priority
2nd Priority
Plan to Change Soon
No Change Planned
No Change Needed
Quit tobacco?
1st Priority
2nd Priority
Plan to Change Soon
No Change Planned
No Change Needed
Increase physical activity?
1st Priority
2nd Priority
Plan to Change Soon
No Change Planned
No Change Needed
Eat healthier?
1st Priority
2nd Priority
Plan to Change Soon
No Change Planned
No Change Needed
Reduce stress?
1st Priority
2nd Priority
Plan to Change Soon
No Change Planned
No Change Needed
2) Are you pregnant?
Yes
No
No, but I’m planning to become pregnant in the next 6 months
N/A
3) Would you be interested in talking one-on-one with a registered nurse or health coach about the best ways to care for your health?
Yes
No
Your signature
Today’s date
Phone number (including area code)
(MM/DD/YYYY)
/
/
To be completed by physician: Health history and biometrics
1) Tobacco use: Has the member used tobacco or any nicotine replacement products in the last 90 days?
Yes
No
2) Medical history (Select all that apply)
Asthma
Atrial Fibrillation
CAD
COPD
Diabetes
Heart Failure
High Blood Pressure
High Cholesterol
Low Back Pain
Stroke
__________________________________________________________________
Other
3) Weight (in pounds) __________
Height ______ ft. ______in.
even
¼
½
¾
Date of screening for the following results:
/
/
Blood pressure 1 ________ /________
mm Hg
Blood pressure 2 ________ /________
mm Hg
(Repeat if above 140/90, and record in next box)
Blood glucose
_________
________________ mg/dL
Fasting
Non-fasting
HbA1C
%
Total cholesterol _________
_______
_______
________
mg/dL LDL cholesterol
mg/dL HDL cholesterol
mg/dL Triglycerides
mg/dL
Physician’s name
Today’s date (MM/DD/YYYY)
Phone number (including area code)
/
/
Physician’s signature (or representative completing the form)
Submit your Health Screening Physician Form to Carewise Health by any of these methods:
•
Fax:
877-719-3734
•
Email:
Questions? Call Carewise Health at: 866-691-8431.
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