Tricity Family Medicine & Urgent Care

Available Forms

0.1: Appointment Request 1: PATIENT DEMOGRAPHIC FORM 2. HIPAA FORM 3: FEES, PAYMENT & BILLING POLICIES 4: CREDIT CARD ON FILE POLICY 5: OFFICE POLICIES 6: LAB BILLING POLICY 7. Lab Result Follow-up question 8. Prescription Refill Request 9. Referral Request/ Question A1. Billing Question Address/Contact Information Update Form Adult Annual Wellness/ Physical Exam Pre-visit Form Blood Pressure Log Blood Sugar Readings Cancer Screening Services Record Update GAD-7 Generalized Anxiety Disorder Healthcare Questions Insurance Update Form Password Request The Mood Disorder Questionnaire (mdq) Z: Patient Satisfaction Survey - Care at Tricity Family Medicine Z: Patient Satisfaction Survey - Community Referral Process Z: Patient Satisfaction Survey - Referral Process (Coordination of Care) Z: Specialist/Hospital Care Coordination Form

Adult Annual Wellness/ Physical Exam Pre-visit Form

Annual Wellness/ Physical Exam Pre-visit Form

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

What is your living situation?

Alone

With my spouse or other family

With a friend or roommate

In a nursing home/ assisted living facility or home

I don't have a place to live

Other

Upcoming Physical Exam/ Annual Wellness Appointment Date

Has it been 365 days since your last Physical Exam? *

Yes

I don't know

Most Health Insurance Plans require 365 days between Physical Exam Dates to meet payment policy. IT IS YOUR RESPONSIBILITY TO KNOW YOUR PHYSICAL EXAM COVERAGE POLICY. The visit will be Patient responsibility should your health insurance plan deny payment due to insufficient time between two Physical Exam visits.

Last Physical Exam/ Annual Wellness Exam Date *

Hospital / Surgery/ Injury since last office visit

Hospital Visits Date/ Hospital/ Doctor/ Reason

Surgery Visits/ Date/Doctor/ Reason

Injury Date/ Type/ Treatment received

Other Physicians & Providers of Care

Name & Specialty Provider Type/ Care received

Past Psychiatric/ Mental Health Care

Do you have history of Past Psychiatric/Mental Health Care *

Yes

If yes, please fill in following details.

Therapist's Name

For how long & when?

Depression Screening

Over the past two weeks, has the patient felt down, depressed or hopeless? *

Yes

Over the past two weeks, has the patient felt little interest or pleasure in doing things? *

Yes

Functional ability/Safety screening

Was the patient?s timed Up & Go test unsteady or longer than 30 seconds?

Yes

Does the patient need help with the phone, transportation, shopping, preparing meals,housework, laundry, medications or managing money? *

Yes

Does the patient?s home have rugs in the hallway, lack grab bars in the bathroom, lack handrails on the stairs or have poor lighting? *

Yes

Have you noticed any hearing difficulties? *

Yes

Do you use hearing aids or other devices to help you hear?

Yes

I don't know

Do you have problem with vision?

Yes

I don't know

Have you fallen in last six months due to loss of balance?

Yes

Elaborate - if you answered YES to any of the above questions

Would you like to discuss any other health or behavioral factors that could affect your Sexually Transmitted Disease (STD) Risks?

Yes

I don't know

STD Risk Factors

Do you suffer from Urinary Incontinence?In the past six months have you experienced leaking of urine?

Yes

I don't know

Do you visit Dentist for regular check ups?

Yes

Do you protect your skin from sun damage by using sunscreen, wearing hats, and/or avoiding tanning booths and sunlamps?

Yes

May be

I don't know

Do your fasten your seat belts in vehicles?

Yes

I don't ride in vehicles

Does your home have working smoke alarms?

Yes

I don't know

Other Preventive Care

Last Physical Exam

Women: Pelvic and breast exam including Pap smear. Men: Physical Exam with prostate

Last Pap Date

Last Mammogram Date

Breast cancer screening

Mammogram/ Physical/ Pap Office Info

Last Colonoscopy Date

Colorectal cancer screening

Colonoscopy office Info

Prostate cancer screenings (PSA)

Last Bone Mass Density (BMD)

BMD performed Office Info

Are your Immunizations Uptodate?

Yes

I don't know

Name of Home Health Agency

Medical Supply Equipment Company

Referral Need

Specialty Type/ Doctor Name / Reason for Referral

Social/ Emotional Support

Which of the following applies to you?

I have a supportive family.

I have supportive friends.

I participate in church, clubs or other group activities.

None

How often do you get out and meet with Family & Friends? *

Often

Sometimes

Almost Never

None

Personal Safety

Because violence and abuse happens to a lot of people and affects their health we are asking the following questions.

How often does anyone, including family and friends, physically hurt you?

Never

Rarely

Sometimes

Fairly often

Frequently

How often does anyone, including family and friends, insult, talk down to you, scream or curse at you or threaten you with harm?

Never

Rarely

Sometimes

Fairly often

Frequently

Social Determinants of Health - AHC HRSN Tool

Food: Within the past 12 months, you worried that your food would run out before you got money to buy more:

Often true

Sometimes true

Never true

Financial Strain: How hard is it for you to pay for the very basics like food, housing, medical care, and heating?

Very Hard

Somewhat hard

Not hard at all

Transportation: In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?

Yes, it has kept me from medical appointments or getting medications

Yes, it has kept me from non-medical meetings, appointments, work, or getting things that I need

Utilities: In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?

Yes

Already shut off

Pain Assessment

In the past two weeks, how often have you felt pain?

Almost all of the times

Most times

Sometimes

Almost Never

No pain

Where is the pain?

How do you treat the pain?

Medication

Rest

Heat or Cold

Therapy

Other

No Treatment Plan

Rate your pain on scale of 0-10

(Pain Rating Scale adopted from McCaffery, Beebe et al. 1989)<br/>?Please indicate the intensity of current, best, and worst pain levels on a scale of 0 (no pain) to 10 (worst pain imaginable)?<br/>1-3: Mild<br/>4-6: Moderate<br/>7-10: Severe

Sleep

How many hours of sleep do you usually get?

0-3 hours

4-6 hours

7-10 hours

10+ hours

I don't know

Do you snore or has anyone told you that you snore?

Yes

I don't know

In the past 7 days, how often have you felt sleepy during the daytime?

Often

Sometimes

Almost Never

Never

I don't know

Habits & Health Goals

How many days or hours per week do you exercise? Type of exercise.

How many servings of fruit/vegetables, meat, grains do you eat per day?

List your Health Goals

Weight, Diet, Cholesterol, Blood Pressure goals, Lifestyle etc

How often do you have trouble taking medicines the way you have been told to take them?

I do not have to take medicine

I always take them as prescribed

Sometimes I take them as prescribed

I seldom take them as prescribed

How confident are you that you can control and manage most of your health problems?

Very confident

Somewhat confident

Not very confident

I do not have any health problems.

Do you have Advance Directive/ Living Will/ Health Power of Attorney present? *

Yes

I don't know

Please ask the provider if you need more information on this.

By checking the box, I agree to the accuracy of information provided here. *

Patient's/ Responsible Party's Full Name *

* Required field