Annual Wellness Form | Regional Primary Care

First Name

Last Name

Email Address

Date of Birth

Date of Medicare Eligibility

Approximate Date of Last Annual Physical

Medication History

Medication

Prescription medications, supplements, over the counter, substances of abuse

Date Started

Date Stopped

Dose and Frequency

Provider who prescribed this medicine

Add Another?

Yes No

Allergy List

Medication or Allergen

Type of Reaction

Add Another?

Yes No

Chronic Medical Conditions

(Ongoing or Long-Term Problems like high blood pressure, diabetes, etc)

Problem

Date of onset

Status

Add Another?

Yes No

Medical/Surgical History

Problem

Date of Surgery, ER Visit, etc.

Facility/Provider

Add Another?

Yes No

Diagnostic Studies

(Indicate any lab tests, xrays, MRI/CT, etc. that you have had recently. Please include the date or approximate date.)

Have you ever had any of the following?

Colonoscopy?

Where was the test performed?

Ordering Provider

Approximate Date

Mammogram?

Where was the test performed?

Ordering Provider

Approximate Date

Flu vaccine?

Where was the test performed?

Ordering Provider

Approximate Date

Pneumonia vaccine?

Where was the test performed?

Ordering Provider

Approximate Date

Would you like to add another Diagnostic Study?

Yes No

Review of Systems

General

Appetite Change Weight Gain Weight Loss Fever Chills Sweats None Other:

Ears

Ringing Hearing Loss Infection Drainage Pain None Other:

Eyes

Visual Changes Double Vision Eye Pain Eye Charge None Other:

Nose/Throat

Nasal Drainage Sinus Pressure Nosebleeds Gum Bleeding Tongue Soreness Difficulty Swallowing Hoarseness None Other:

Lungs

Cough Shortness of Breath Wheezing Coughing Up Blood Known TB Exposure None Other:

Heart

Chest Pain Skipping Beats Shortness of Breath with Exertion Swelling in Legs Pain in Legs when Walking None Other:

Abdomen

Stomach Pain Nausea Vomiting Diarrhea Constipation Black Stools Blood in Stool None Other:

Urinary Tract-Men

Difficulty Urinating Dribbling Trouble Holding Urine Up at Night to Urinate Blood in Urine Discharge from Penis Erectile Dysfunction None Other:

Endocrine

Thyroid Trouble Heat or Cold Intolerance Diabetes Excessive Thirst, Hunger, or Urination None Other:

Emotional

Nervousness Mood Swings Depression Anxiety Difficulty Sleeping None Other:

Skin

Brittle Hair or Nails Hair Loss Mole Changes Rashes Non-heating Lesions None Other:

Joints/Muscles

Backache Pain in Joints Joint Swelling Pain in Muscles Weakness Neck Pain None Other:

Blood/Glands

Easy Bleeding Easy Brusing Swollen Glands Anemia Other : None

Immunologic

Contact Allergy (ie. poison ivy) Food Allergies Seasonal Allergies None Other:

Family History

Deceased

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Hypertension

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Heart Disease

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Stroke

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Kidney Disease

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Obesity

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Genetic Disorder

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Alcoholism

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Liver Disease

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Depression

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Colon/Rectal Cancer

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Breast Cancer

Self

Father

Mother

Sisters

Brothers

Aunts

Uncles

Daughters

Sons

Would you like to list other cancers?

Yes No

Would you like to list any other conditions?

Yes No

Social History

Language/Communication Barrier

Yes

No

Caffeine

Never

Occasional

Daily

Alcohol

Never

Occasional

History of Alcohol Abuse

Drug Abuse

Never

Occasional

Daily

Prior Use

Tobacco Use

Never

Prior

Current

Secondhand Exposure

Home Environment

Private Home

Assisted Living

Other

Exercise

Daily

Weekly

Ocassional

Never

Other Providers of Care (Includes Specialists, Chiropractors, Therapists, In-Home Care, etc.)

Provider Name

Type of Care

Date of Last Visit

Add Another?

Yes No

Acute Problems (Current or new problems since your last office visit.)

Type of Problem

Add Another?

Yes No

Date of Onset

Managing Provider

Status

Resolved Ongoing

Today's Date : 09/19/2024