Family Healthcare of Fairfax, PC Patient Portal

Available Forms

Adult Gyn History Cryobank Covid-19 and Health Screening Form Cryobank Health History Questionnaire Cryobank Patient Registration Form Financial Policy Health History Questionnaire HIPAA Form Immigration New Patient Registration Form Immigration Physical - Patient Health History Questionnaire Influenza Vaccine Consent Form New Patient Registration Form Patient Pre-Visit Covid-19 Screening Physical Exam Form

Physical Exam Form

Family Healthcare of Fairfax, PC

Please fill as completely as you can. If not sure, leave blank.

Name and Age: *

Date of Birth: *

Date of Visit *

Do you or your family suspect you have hearing loss? *

Would you like to be tested today? *

Does anyone, including family, threaten or abuse you physically, verbally, or emotionally? *

Within the past 12 months, have you had difficulty paying for food, utilities, bills, or home repair or difficulty finding transportation or childcare? *

Do you need help with any of the above social needs? *

Are you at risk for sexually transmitted diseases?

Would you like to be tested?

Have you ever had a blood transfusion,or accidental needle stick or IV drug abuse? *

Have you been bitten by a tick in the last year? *

Are you frequently exposed to ticks or mosquitoes? *

Do you snore often? *

Have family members ever commented that you have pauses in your breathing during sleep? *

Check all that apply:

Have Sleep Apnea

Have CPAP

Use CPAP

Are you concerned that you have reached a point that you should stop driving? *

Are family members concerned about your driving? *

Have you had any falls or serious injuries in the last year? *

Do you worry about any particular health problems or diseases?

Is there anything else you would like to discuss at your visit? Do you need any refills? If yes, please list.

Physical Exam Part 1:

Please check all boxes that apply to you:

GENERAL SYMPTOMS: *

Good health lately

Recent significant weight change

Unusual fatigue or weakness

EYES:

Change in vision

Eye disease or injury

Floaters, spots, or flashes

EAR / NOSE / THROAT / NECK

Hearing loss or ringing in ears

Earaches or sinus problems

Nose bleeds

Mouth sores

Sore throat/ hoarseness/ voice change

Thyroid enlargement/ thyroid disease

Neck pain or stiffness

CARDIOVASCULAR: *

No cardiovascular problems

Chest / neck/ arm discomfort with exercise

Palpitations, skipped beats, racing heart

Shortness of breath during activity

Shortness of breath during rest

Swelling of feet, legs, ankles or hands

RESPIRATORY: *

No respiratory problems

Persistent cough or sputum production

Coughing or spitting up blood

History of pneumonia, emphysema

Asthma, history of asthma, wheezing

History of smoking >10 years

GASTROINTESTINAL: *

No gastrointestinal problems

Nausea or vomiting

Chronic heartburn

Painful bowel movements/ constipation

Frequent diarrhea

Rectal bleeding or blood in stools

Black or tarry stools

Stomach or abdominal pain

Difficulty swallowing

GENITOURINARY:

If using birth control, what method?

Include number of pregnancies and number of live births:

Date of last period:

MUSCULOSKELETAL:

Joint pain, stiffness, swelling, or warmth

Weakness of muscles

Back pain

Cold hands or feet

Difficulty walking

SKIN & BREAST

Rashes / itching

Change in skin color or moles

Change in hair or nails

Varicose veins

Breast pains or lumps or discharge

Perform monthly breast self-exams

NEUROLOGICAL:

Frequent or recurring headaches

Light headedness or dizziness

Convulsions, seizures, or "spells"

Numbness or tingling sensation

Tremors or pain in hands and feet

Balance or gait issues, unexpected falls

Head injury

MENTAL HEALTH

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Memory loss or confusion *

Nervousness, anxiety, frequent worries *

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 usual *

Thoughts that you would be better off dead or of hurting yourself *

How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *

SOCIAL HISTORY:

Currently smoke?

Previously smoked?

If yes, enter your quit date:

Consume alcohol?

If yes, include the amount you consume per day:

Do you exercise regularly? *

Do you diet?

Have you received any immunizations in the last year? if yes, which ones, when, where? *

Please type any other concerns you may have:

* Required field