Annual Physical Exam

Annual Physical Exam

This is for comercial insurance only, not for medicare patients
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Today’s Date

MonthDayYear
Date
All questions are completely confidential. The forms get scanned into your chart.

Question

Rows	Yes	No	Skip
1 Do you get 3 servings of calcium-rich foods daily (milk, cheese, yogurt)?
2 Do you eat fruits and vegetables every day?
3 Do you limit the amount of fried food or fast food that you eat?
4 Do you drink a soda, juice drink, sports or energy drink most days of the week?
5 Are you concerned about your weight?
6 Do you exercise (walking, gardening, swimming) at least ½ hour a day?
7 Do you feel safe where you live?
8 Have you been hit, slapped, kicked, or physically hurt by someone in the last year?
9 Do you always wear a seat belt when driving or riding in a car?
10 Do you keep a gun in your house or place where you live?
11 Do you often have trouble sleeping?
12 Do you smoke or chew tobacco?
Do friends or family members smoke in your house or place where you live? 13
14 Do you use medicines to help you sleep, relax, calm down, feel better?
15 Do you think you or your partner could be pregnant?
16 Do you think you or your partner has an STD, such as Chlamydia, Gonorrhea, etc.?
17 Have you or your partner(s) had sex without using birth control in the past year?
18 Have you or your partner(s) had sex with other people in the past year?
19 Have you or your partner(s) had sex without a condom in the past year?
20 Have you ever been forced or pressured to have sex?
21 Do you have other questions or concerns about your health?

Rows	Not at all	Several Days	More than half the days	Nearly Every Day
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 let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed, or the opposite –being so fidgety or restless that you have been moving around a lot more than
Thoughts that you would be better off dead or of hurting yourself in some way

Rows	Not at all	Several Days	More than half the days	Nearly Every Day
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

Rows	Not at all	Less than 1/5 times	Less than ½ the time	About ½ the time	More than ½ the time	Every Day
Incomplete Emptying: How often have you had a sensation of not emptying your bladder completely after you finish urinating?
Frequency: How often have you had to urinate again less than two hours after you finished urinating?
Intermittency: How often have you found you stopped and started again several times when you urinated?
Urgency: How difficult have you found it to postpone urination.
Weak Stream: How often have you had a weak urinary stream?
Straining: How often have you had to push or strain to begin urinating?

Alcohol Use Questionaire