Annual Health Assessment
Patient
Name
First Name
Middle Name
Last Name
Suffix
Birthday
-
Month
-
Day
Year
Date
Age
Physical Activity
How many days a week do you exercise?
*
Never
Rarely Ever
1-2 Days Per Week
3-4 Days per week
5 or More Days
Other
How many minutes do you exercise per day?
Not Applicable
Less than 30
30-60 Minutes
60-90 Minutes
More than 90 Minutes
Other
How Intense is your typical exercise?
Not Applicable
Light (like stretching or slow walking)
Moderate (like brisk walking)
Heavy (like jogging or swimming)
Very heavy (like fast running or stair climbing)
Tobacco Use
Do you Smoke?
*
No
Yes
Do you Vape?
*
No
Yes
Do you use smokeless Tobacco?
*
No
Yes
Are you interested in quitting?
*
No
Yes
Alcohol Use
Have you used alcohol in the past 7 days?
*
No
Yes
On days when you drank alcohol, how often did you have 4 or more drinks?
Not Applicable
Never
Once during the 7 days
2-3 times during the 7 days
More than 3 times during the 7 days
Other
Do you ever drink and drive or ride with someone who is drinking and driving?
No
Yes
Nutrition
How many servings of fruits and vegetables do you eat per day?
None
1-2 Servings
3-5 Servings
Other
How many servings of high fiber or whole grain food do you eat per day?
None
1-2 Servings
3-5 Servings
Other
How many servings of fried or high-fat foods do you eat per day?
None
1-2 Servings
3-5 Servings
Other
How many sugar-sweetened drinks do you have per day?
None
1-2 Servings
3-5 Servings
Other
Depression
In the past 2 weeks, how often have you felt down, depressed or hopeless?
Never
All of the time
Some of the time
Most of the time
In the past 2 weeks, how often have you felt little interest or pleasure in doing things?
Never
All of the time
Some of the time
Most of the time
Have your feelings caused you distress or interfered with your ability to get along socially with family or friends?
No
Yes
Other
Anxiety
In the past 2 weeks, how often have you felt nervous, anxious or on edge?
Never
All of the time
Some of the time
Most of the time
In the past 2 weeks, how often were you not able to stop worrying or control your worrying?
Never
All of the time
Some of the time
Most of the time
High Stress
How often is stress a problem for you in handling such things as your health, your family or social relationships and your finances?
Never
All of the time
Some of the time
Most of the time
Social and Emotional Support
How often do you get the social and emotional support you need:
Always
Usually
Sometimes
Rarely
Never
Pain
In the past 7 days, how much pain have you felt?
None
Some
A Lot
Other
What is your current pain level?
0
1
2
3
4
5
6
7
8
9
10
None
Worst
0 is None, 10 is Worst
General Health
In general, would you say your health is?
Excellent
Very Good
Good
Fair
Poor
How would you describe the condition of your mouth and teeth, including false teeth and dentures?
Excellent
Very Good
Good
Fair
Poor
Activities of Daily Living
In the past 7 days have you needed help with daily living activities? Such as eating, getting dressed, grooming, bathing, walking or using the toilet?
No
Sometimes
Yes
Instrumental Activites of Daily Living
In the past 7 days have you needed help with instrumental daily living activities? Such as banking, shopping, housekeeping, laundry, telephone, food preparation, transportation or taking medications?
No
Yes
Sleep
How many hours of sleep do you get a night?
less than 4
4-6
6-8
more than 8
Do you snore or has anyone told you that you snore?
No
Yes
Do you feel sleepy during the daytime?
Always
Usually
Sometimes
Rarely
Never
BMI
Weight in Pounds
Height Feet
Height in Inches
BMI VALUE
BMI Reference
Blood Glucose
If your glucose was checked, what was your fasting blood glucose (blood sugar)?
Other Providers
Please list any specialists that you see along with their name, phone number and the last time that you saw them (approximately)
Who
Phone
When
Cardiologist (Heart)
Neurologist (Brain)
Dentist (teeth)
Endocrinologist (thyroid/diabetes)
Gastroenterologist (stomach/liver)
Nephrologist (Kidney)
Oncologist (Cancer)
Ophthalmologist (Eyes)
Podiatrist (foot)
Pulmonologist (Lungs)
Psychiatrist (Mental Health)
Orthopedics (Bone and Joint)
Pian Clinic
Gynocologist
Other
Special Exams
When
Where
Colonoscopy
Pap smear
Mammogram
Dexa Scan
Eye Exam
Special Tests
When
Where
Last SUMACR
Last PSA
Last Neuropathy Screening
Last Diabetic Foot Exam
Submit
What Office?
*
Centerville
Bainbridge
Email
Todays Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: