- Publicforms

Available Forms

Alignment Care Center Appointment Request Alignment Referral Form Back Pain E-Visit Blood Pressure Log Blood Sugar Readings Cold/Sinus/Cough/Throat/Respitory Infaction E-Visit Conjunctivitis/Pink Eye E-Visit Depression Screening (PHQ9) Health Care Question Lab Result Follow-up Question Living Will/Health Power of Attorney Medical History/Preventative Update Medicare Wellness Exam Prescription Refill Request Referral Question Specialist/Urgent Care or Hospital Visits Survey Triangle Medical Group Urinary Tract Infection E-Visit Yeast Infection E-Visit

Medical History/Preventative Update

First Name *

Last Name *

Date Of Birth *

Insurance Type *

Alignment

Medicare

Blue Cross

United Healthcare

Cigna

Humana Gold

First Carolina

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/>

Choose your medical practice

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