Section 1 of 1
Wellness Form
Please take a few minutes to fill out this information so we may expedite the question portion and give complete attention to your wellness exam
Patient's name?
Patient's name?
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Patient's date of birth
Patient's date of birth
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Patient Address
Patient Address
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Today's date
Today's date
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What is your gender?
What is your gender?
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What is your address?
What is your address?
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Little interest or pleasure in doing things?
Little interest or pleasure in doing things?
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Time
Not at all
Several days
More than half of the days
Nearly every day
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add "Other"
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Feeling down, depressed or hopeless?
Feeling down, depressed or hopeless?
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Not at all
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Nearly every day
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Trouble falling or staying asleep or sleeping too much?
Trouble falling or staying asleep or sleeping too much?
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Not at all
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Nearly every day
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Feeling tired or having little energy?
Feeling tired or having little energy?
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Not at all
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Nearly every day
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Poor appetite or overeating?
Poor appetite or overeating?
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Nearly every day
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Feeling bad about yourself OR that you are a failure OR have let your family down?
Feeling bad about yourself OR that you are a failure OR have let your family down?
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Nearly every day
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Trouble concentrating on things such as reading newspapers or watching television?
Trouble concentrating on things such as reading newspapers or watching television?
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Not at all
Several days
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Nearly every day
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Moving or speaking so slowly that other people have noticed or the opposite, being so fidgety or restless that you have been moving around a lot more than usual?
Moving or speaking so slowly that other people have noticed or the opposite, being so fidgety or restless that you have been moving around a lot more than usual?
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Not at all
Several days
More than half of the days
Nearly every day
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Thoughts that you would be better off dead or hurting yourself in some way?
Thoughts that you would be better off dead or hurting yourself in some way?
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Not at all
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Nearly every day
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In general how would you rate your health?
In general how would you rate your health?
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Poor
Fair
Good
Very good
Excellent
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In the past 7 days, have you needed help from others to eat, bathe, use the toilet, or do laundry?
In the past 7 days, have you needed help from others to eat, bathe, use the toilet, or do laundry?
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Yes
No
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Do you exercise or do moderate physical activity such as walking 30 minutes per day?
Do you exercise or do moderate physical activity such as walking 30 minutes per day?
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Yes
No
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On a scale from 0-10 where 0 is none and 10 is the highest, what is your pain level today?
On a scale from 0-10 where 0 is none and 10 is the highest, what is your pain level today?
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0
1
2
3
4
5
6
7
8
9
10
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Where is the pain?
Where is the pain?
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Do you have a living will?
Do you have a living will?
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Yes
No
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Do you have a copy of your living will on file?
** If so please bring a copy into the office so that we can scan it and save it to your record
Do you have a copy of your living will on file?
** If so please bring a copy into the office so that we can scan it and save it to your record
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Yes
No
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Do you use a hearing aid?
Do you use a hearing aid?
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Yes
No
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When and where was your last colonoscopy?
Month:
Year:
Location:
When and where was your last colonoscopy?
Month:
Year:
Location:
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What were the results of your last coloscopy?
What were the results of your last coloscopy?
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Normal
Polyps
Unknown
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What were the results of your last Cologuard?
What were the results of your last Cologuard?
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Normal
Abnormal
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When is your next colon screening due? Don't answer if repeat screening is not due.
When is your next colon screening due? Don't answer if repeat screening is not due.
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When and where was you last eye exam?
Month:
Year :
Location
When and where was you last eye exam?
Month:
Year :
Location
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When and where was your last foot exam?
Month:
Year:
Location:
When and where was your last foot exam?
Month:
Year:
Location:
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Have you had any falls within the past year?
Have you had any falls within the past year?
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No
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If you fell, how many times? Did you injure yourself?
If you fell, how many times? Did you injure yourself?
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Did you have a drink containing alcohol in this past year?
Did you have a drink containing alcohol in this past year?
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Yes
No
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If yes, HOW OFTEN did you have a drink and HOW MANY drinks do you typically have when drinking?
If yes, HOW OFTEN did you have a drink and HOW MANY drinks do you typically have when drinking?
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How often did you have 6 or more drinks on one occasion?
How often did you have 6 or more drinks on one occasion?
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Do you have urinary incontinence?
Do you have urinary incontinence?
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Do you use nicotine products?
Do you use nicotine products?
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Yes, I am a current nicotine user
No I have never used nicotine
Former nicotine user
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add "Other"
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If you are a current nicotine user, what do you typically use?
If you are a current nicotine user, what do you typically use?
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Smoke
Chew
Vape
Patch
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If you use nicotine, how often and how much do you use typically? When did you start?
If you use nicotine, how often and how much do you use typically? When did you start?
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Do you use CBD/ THC and how often do you use it? When did you start?
Do you use CBD/ THC and how often do you use it? When did you start?
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What is your current housing situation?
What is your current housing situation?
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I have housing
I do not have housing ( living with others, in a hotel, in a shelter, living outside on the street, beach or park)
I choose not to answer this question
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Are you worried about losing your housing?
Are you worried about losing your housing?
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No
I choose not to answer this question
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What is the highest level of school that you have finished?
What is the highest level of school that you have finished?
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Less than a high school degree
High school diploma/ GED
More than high school
I choose not to answer this question
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What is your current work situation?
What is your current work situation?
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Unemployed and seeking work
Part time or temporary work
Full time work
Unemployed and not seeking work (student, retired, disabled, unpaid primary care giver)
I choose not to answer this question
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In the last year, have you or your family members that you live with been unable to get any of the following when it was really needed? Check all that apply:
In the last year, have you or your family members that you live with been unable to get any of the following when it was really needed? Check all that apply:
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Food
Clothing
Utilities
Child care
Medicine any health care (medical, dental, mental health or vision)
Phone
I do not have problems meeting my needs
I choose not to answer this question
Other
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If you answered "other" on the previous question please explain:
If you answered "other" on the previous question please explain:
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Has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?
Has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?
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Yes, it has kept me from medical appointments or from getting my medications
Yes, it has kept me from non-medical meetings, appointments, meeting, work or from getting things for daily living
No
I choose to answer this question
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How often do you see or talk to people that you care about and feel close to?( For example: talking to friends on the phone, visiting friends or family, going to church or group meetings
How often do you see or talk to people that you care about and feel close to?( For example: talking to friends on the phone, visiting friends or family, going to church or group meetings
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Less than once a week
1-2 times a week
3-5 times a week
More than 5 times a week
I choose not to answer the question
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Do you feel physically and emotionally safe where you live?
Do you feel physically and emotionally safe where you live?
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Yes
No
Unsure
I choose not to answer this question
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In the past year have you been afraid of you partner or ex partner?
In the past year have you been afraid of you partner or ex partner?
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No
Unsure
I have not had a partner this past year
I choose not to answer this question
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This Healthcare Practice recognizes that every patient has the Right of Privacy concerning their personal health
information. We make every effort to protect and preserve patient records in a manner that secures this information.
By signing the acknowledgement:
You are only confirming that you understand our PRIVACY PRACTICES.
You do not give up any of your rights and you may choose at some point in the future to provide more specific instructions
for us to follow regarding your personal health information.
I UNDERSTAND OR I HAVE REQUESTED A COPY OF THIS OFFICE¶S NOTICE OF PRIVACY PRACTICES. Type your name below if you agree.
This Healthcare Practice recognizes that every patient has the Right of Privacy concerning their personal health
information. We make every effort to protect and preserve patient records in a manner that secures this information.
By signing the acknowledgement:
You are only confirming that you understand our PRIVACY PRACTICES.
You do not give up any of your rights and you may choose at some point in the future to provide more specific instructions
for us to follow regarding your personal health information.
I UNDERSTAND OR I HAVE REQUESTED A COPY OF THIS OFFICE¶S NOTICE OF PRIVACY PRACTICES. Type your name below if you agree.
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´I acknowledge that I received and read the Notice of Health Information Practices. I understand that my
healthcare provider participates in Health Current, Arizona's health information exchange (HIE). I understand
that my health information may be securely shared through the HIE, unless I complete and return an Opt Out
Form to my healthcare provider.µ
´Reconozco que recibí y leí el Aviso de Prácticas de Información de Salud. Entiendo que mi proveedor de
salud participa en Health Current, el intercambio de información sobre la salud de Arizona (HIE ² por sus
siglas en inglés). Entiendo que mi información de salud puede ser compartida de forma segura a través del
HIE, a menos que complete y regrese una Forma (Opt Out) sobre la opción de no participar del paciente a mi
proveedor de salud.µ
Type your name if you agree
´I acknowledge that I received and read the Notice of Health Information Practices. I understand that my
healthcare provider participates in Health Current, Arizona's health information exchange (HIE). I understand
that my health information may be securely shared through the HIE, unless I complete and return an Opt Out
Form to my healthcare provider.µ
´Reconozco que recibí y leí el Aviso de Prácticas de Información de Salud. Entiendo que mi proveedor de
salud participa en Health Current, el intercambio de información sobre la salud de Arizona (HIE ² por sus
siglas en inglés). Entiendo que mi información de salud puede ser compartida de forma segura a través del
HIE, a menos que complete y regrese una Forma (Opt Out) sobre la opción de no participar del paciente a mi
proveedor de salud.µ
Type your name if you agree
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INFORMATION TO BE RELEASED: 1 Year of Records ONLY
INFORMATION TO BE RELEASED: 1 Year of Records ONLY
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Last Mammogram
Dexa
Colonoscopy
Last OV note
Imaging
Labs
Other
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I authorize the release and disclosure of the above information as follows:
RECEIVING FROM: PLEASE SEND RECORDS TO:
Doctor/Facility: ____________________________
Doctor/Facility: GRAND MEDICAL ASSOCIATES
Address: Address: 14674 W MOUNTAIN VIEW BLVD #200
SURPRISE, AZ. 85374
Phone: Phone: 623-544-6860
Fax: Fax: 623-544-6861
***YOU MUST PROVIDE A FAX NUMBER SO THAT WE MAY
REQUEST YOUR RECORDS***
I authorize the release and disclosure of the above information as follows:
RECEIVING FROM: PLEASE SEND RECORDS TO:
Doctor/Facility: ____________________________
Doctor/Facility: GRAND MEDICAL ASSOCIATES
Address: Address: 14674 W MOUNTAIN VIEW BLVD #200
SURPRISE, AZ. 85374
Phone: Phone: 623-544-6860
Fax: Fax: 623-544-6861
***YOU MUST PROVIDE A FAX NUMBER SO THAT WE MAY
REQUEST YOUR RECORDS***
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