PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS

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Sheila Hill
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1 UF Health Senior Care PO Box Gainesville, FL Fax PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS Please complete this questionnaire at home and bring it with you to the clinic on the day of your appointment. Referral Source: Who may we thank for referring you? Name: Date of birth: Marital status: Single Married Divorced Widowed Current living arrangement: Live with spouse With friend With relative(s) Alone Please indicate highest educational grade completed: K 12: K College (Please indicate number of years and degree(s) obtained): Occupation (now and before retirement): Religious preference: Do you have a living will or power of attorney for health care? If yes, please bring a copy of your document to clinic.

2 CHIEF COMPLAINTS OR CONCERNS: LIST OF MEDICAL PROBLEMS: PREVIOUS SURGERIES:

3 PREVIOUS PRIMARY CARE PROVIDER: Name: Address: City: State: Zip: Phone Number: List all current medical providers: Do you exercise on a regular basis? What kind of exercise do you usually do? How many days per week do you usually exercise? Do you currently use tobacco in any form? Cigarettes Cigars Pipe Snuff Chewing tobacco Other Years of use How often do you use alcohol? (please circle one answer) Rarely or Never One to 3 days per week 4-6 days per week Daily How many drinks do you consume at a time? (please circle one answer) One to two drinks per day 2-4 drinks per day 5 or more drinks per day

4 If you use alcohol, please answer yes or no to the following questions: 1- Have you ever considered cutting down on your alcohol intake? 2- Do people annoy you by criticizing your drinking? 3- Have you ever felt bad or guilty about your drinking? 4- Have you ever had an alcoholic drink first thing in the morning to steady your nerves or get rid of a hangover? Do you use illicit drugs? If yes, what type of drug(s) do you use? Frequency of use? FAMILY HISTORY: High blood pressure Diabetes Heart disease Stroke Dementia Depression Osteoporosis Breast cancer Prostate cancer Colon cancer (bowel cancer) Other: Family member with problem HEALTH MAINTENANCE HISTORY: Please mark if you have received the following vaccinations and indicate approximate date of the last dose: Vaccinations Influenza (Flu) Pneumococcal (pneumonia vaccine) Tetanus/diphtheria Zostavax(shingles) Date of last dose (approximate)

5 Did you ever have a colonoscopy? If yes, when was your last one? Please describe results. Have you ever been tested for osteoporosis (thinning of the bones)? If yes, when? Please describe results. Do you see a dentist and a dental hygienist on a regular basis? If yes, when was your last visit? Do you see an ophthalmologist (eye doctor)? If yes, when were you last seen by your eye doctor? For men only (next 2 questions): 1- Have you ever had PSA (prostate specific antigen) testing? If yes, when was your last one? Please describe results. 2- Have you had a digital examination of your prostate? If yes, when was your last one? Please describe results. For women only (next 4 questions): 1- Do you see a gynecologist on a regular basis? If yes, when was your last consultation? 2- Have you had mammograms? If yes, when was your last one? Please describe results. 3- When was your last breast examination by a doctor? Do you perform breast self examinations? If yes, please describe how often.

6 4- When was your last pelvic examination? When was your last PAP smear? Have you had any abnormal PAP smears? If yes, when? LIST OF YOUR CURRENT MEDICATIONS (PLEASE INCLUDE YOUR PRESCRIPTION, OVER-THE-COUNTER, VITAMINS AND HERBAL SUPPLEMENTS) Name of medication Dose Time of the day medication is taken Do you have allergies to medications? If yes, please list medications you are allergic to and the type of reaction you had Do you drive? Do you have any difficulties driving during the day or at night? If yes, please describe.

7 Have you been involved in any car accidents over the past 2 years? If yes, please describe. Do you have difficulty in performing any of these activities? Eating Transferring from bed to chair Dressing Walking around the house Toileting Bathing Doing light house work Preparing meals Using the telephone Taking medications Paying bills Using public transportation Shopping Running errands No Require Assistance Yes In general, how would you rate your vision? (Please circle best answer) Excellent Very good Good Fair Poor Do you ever feel that problems with your vision make it difficult for you to do the things you would like to do? Do you use dentures? If yes, please circle the type of dentures: Upper full denture Lower full denture Upper partial denture Lower partial denture PLEASE ANSWER YES OR NO TO EACH ITEM BELOW YOU HAVE RECENTLY EXPERIENCED AND PROVIDE COMMENTS AS NEEDED: Weakness Weight loss Weight gain Fever YES NO Comments

8 Hot Flashes Difficulty hearing Discharge from the ear Recurrent nose bleeds Nasal congestion Persistent hoarseness Chewing difficulties Cough, mostly dry Cough up phlegm Cough up blood Shortness of breath Chest pain with breathing/cough Do you use oxygen during the day? Do you use oxygen during sleep? Chest pain with exertion Shortness of breath with lying down Palpitations (heart racing) Leg pain with exertion Nausea/vomiting Diarrhea Constipation Abdominal pain Blood in stools Heartburn Swallow difficulties Difficulty getting enough food to eat Join pain Joint swelling Joint stiffness Muscle pain Back pain Anxiety Double vision Fainting Skin rash Skin itching Dry skin Changing moles Hair loss YES NO Comments

9 Increased urinary frequency Difficulty passing urine Blood in urine Interested in sex? Are you sexually active? YES NO Comments Women only (next 5 items): YES NO Comments Breast pain Breast mass Vaginal discharge Vaginal bleeding Pain with sex (vaginal intercourse) Men only (next 4 items): YES NO Comments Erectile dysfunction Painful erection Testicular pain Testicular mass How often do you leak urine? Never Once or less than once a day More than once a day All the time Overall, how much does leaking urine interfere with your everyday life? Not at all a great deal Over the past month, how many times did you typically get up to urinate from time you went to bed until the time you got up in the morning? How much does waking up from sleep for urination bother you? Not at all a great deal How often do you have a problem with leakage of stool? Never Less than once a month 2-3 times per month At least once a week Daily

10 Are you able to ambulate independently? Do you use any assistive device for ambulation? YES NO Comments If YES, please indicate type of device: Do you have difficulty climbing one flight of stairs? Do you have difficulties walking two blocks? Do you have problem with keeping your balance? How many times did you fall in the last 12 months? Where did the fall(s) occur (please circle)? Inside your home Outside your home Were there injuries as a result of the fall(s)? If so, please describe the type of injury: Do you have fear of falling? Do you limit you activities because of fear of falling? During the past month, have you often experienced feeling down, depressed, or feeling hopeless? During the past month, have you often experienced having little interest or pleasure in doing things? In general, how would you say your memory is? Excellent Very good Good Fair Poor Are you concerned or worried that you have a memory problem? Is your spouse, relative or friend concerned or worried that you may have memory problems?

11 In general, how would you rate the quality of your sleep? Excellent Very good Good Fair Poor What time do you usually go to bed at night? What time do you usually get out of bed in the morning (to start the day)? Please answer YES or NO to the following questions: Do you usually have difficulty falling asleep? Do you wake up in the middle of the night and have difficulty going back to sleep? Do you have a problem waking up too early in the morning? Do you feel sleepy during the day? Do you take a nap during the day? Do you doze off while sitting during the day? Have you ever been told that you snore? Do you have restless legs? Do you usually have bad dreams? Do you act out your dreams? Are you afraid of anyone in your life? Are you able to use the telephone anytime you want to? Has anyone forced you to do things you didn t want to? Has anyone taken things or money that belong to you without your OK? Has anyone close to you tried to hurt you or harm you recently? Have you had your annual Medicare Wellness visit? Would you like to discuss Advanced Directives?

Address Street Address City State Zip Code. Address Street Address City State Zip Code

Address Street Address City State Zip Code. Address Street Address City State Zip Code Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail