CARY ADULT MEDICINE - Publicforms

Available Forms

1-Medicare Required Screenings 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 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

1-Medicare Required Screenings

Please complete this form if you were directed by our clinic to do so

Name *

Date of Birth *

Over the last 2 weeks how often have you been bothered by any of the following problems?

Little Interest or Pleasure in Doing Things *

Feeling Down Depressed or Hopeless *

Trouble Falling or Staying Asleep or Sleeping too much

Feeling Tired or having Little Energy *

Poor Appetite or Overeating

Feeling bad about yourself or that you are a failure or have yourself or your family down

Trouble Concentrating on things such as reading the newspaper or watching TV

Moving or speaking slowly that other people could have noticed or the opposite- being so figety or restless that you have been moving around a lot more than usual *

Thoughts that you would be better off dead or of hurting yourself

If you checked off any problems how difficult have the problems made it for you to do your work, take care of things at home or get along with other people

If you are between 65 and 75 please list the approximately last time you had a colonoscopy , cologuard or stool test for colon cancer or are scheduled to have one in this coming year

If you are female and between 65-75 please give approximate date of last mammogram or upcoming scheduled mammogram

If you are on blood pressure please list both the average top number (systolic) and bottom number (diastolic) of your average readings at home

* Required field