If you are human, leave this field blank.
Patient's Name: *
Date of Birth: *
Exam Date: *
Primary Care Provider: *
In general, how would you rate your health? * Excellent Very Good Good Fair Poor
How often do you get social/emotional support? * All of the time More than half the time Half the time Less than half the time Rarely Not at all
How often do you take your medications as directed? * Always Sometimes Seldom I do not take any medications
How often do you use your seatbelt? * All of the time Some of the time Rarely or not at all Please select any activities that you need help with (check all that apply): * Do you have trouble controlling your bladder? * Please select anything that applies to how your hearing affects your life: * Please select all that applies to you or your home: * Have you fallen in the year" * Do you feel unsteady when standing or walking? * Do you worry about falling? * Family Health History | Particularly your parents or siblings (check all that apply): *
Past personal illnesses, injuries, operations or diagnosis (please include dates and if you were hospitalized for each): *
What is your occupation? *
Who do you live with? *
Days per week that you eat a well balanced meal? *
What is your caffeine intake per day? *
Number of high-fat foods you have per day? *
Number of servings of fruits and vegetables you have per day? *
How often you eat out per week? *
How often you read food labels? *
Your weight over the past year? * Stable Decreased > 10lbs Increased > 10lbs Other (explain) Your weight over the past year?
How many times do you exercise per week? *
If you exercise, what is the duration?
If you exercise, what is the type?
If yes, smoke or chew? How many packs per day? *
If yes, how many drinks per day?
If yes, descibe:
Current list of patient's providers/specialists/medical equipment suppliesers (please include Name, Specialty and Reason): * I consent to discuss end-of-life issues with my healthcare provider: *
Parent/Guardian Name (this is your Electronic Consent): *
Date * My Choice Advanced Directives (you may upload My Choice Advanced Directives form or print it out and bring with you): POLST (you may upload POLST form or print it out and bring with you):