CARY ADULT MEDICINE - Publicforms

Available Forms

Back Pain E-Visit Billing Question Blood Pressure Log Blood Sugar Readings Cold/Flu/Sinus/Cough//Throat/Respiratory Infection Comments or Suggestions Conjunctivitis/Pink Eye Depression Screening (PHQ9) Flu Shot Health Care Question HIPPA Hospitalization Insurance Change Form Lab Result Follow-up Question Living Will/Health Power of Attorney Medical History/Preventative Update Medicare Wellness Exam New Patient Medical History New Patient Registration Form On Demand Appointment Registration Password - Patient Request for Secure Password Patient Education Classes Prescription Refill Request Preventative Care Referral Question Specialist/ER/Hospital/Testing Update Specialist/Urgent Care or Hospital Visits Survey- Cary Adult Medicine Telemed Urinary Tract Infection Voluntary Alignment for Medicare ACO REACH Yeast Infection

Medical History/Preventative Update

First Name *

Last Name *

Date Of Birth *

Insurance Type *

Medicare

Blue Cross

United Healthcare

Cigna

Other

Approximate Date Last Office Visit

If you have been admitted to hospital or visited the ER since your last office visit please tell us the reason for your admission or vist

Current Smoking Status

Please list new, dropped or changed medications since your last visit. (Include dose, frequency and changed/dropped/added)

Please List Approximate Date of Last Proceedure

Mammogram

Females age 40-75 (Every two years or more frequently if recommended by your physician)

Pap Smear

Females ages 20-65 (Frequency every 1-5 years depending on physician recommendation)<br/>

Colonoscopy

All individuals over age 50 -75 or other high risk individuals identified by your physician. Frequency is every 1,3 ,5 or 10 years based on the results and your risk factors<br/>

Flu Shot

Pneumonia Shot

All individuals over 65 or older or other individuals identified as high risk by a physician should receive the vaccine

If you have received the pneumonia shot which shot did you receive?

Aortic Ultrasound

Male 65-75 that has smoked more than 100 cigs in lifetime

Bone Density

Female > 50 or Male or Female identified by your physician at high risk

If you are on medication for cholesterol diabetes high blood pressure or any heart condition , approximate date of last blood test

Any other changes to your medical condition you would like to update us on?

* Required field