Flagstaff Family Physicians, P.C -Robert Yee, M.D.

Available Forms

Alcohol Questionnaire- AUDIT -C *new patient form* Depression Health Questionnaire (PHQ-9) *new patient form* HIPAA *new patient form* Intake Questionnaire *new patient form* Medical Records Release *new patient form* Medicare Wellness Survey (Medicare Required) Patient Registration Form *new patient form* Payment Policy *new patient form* Physical Exam Form Required

Intake Questionnaire new patient form

Flagstaff Family Physicians, PC

Robert S. Yee, M.D.

710 N. Beaver Street Building 3 Flagstaff, Arizona 86001

Telephone # 928-226-1454

Patient Demographics

Last Name, First Name, Middle Inital *

Best Method of contacting you *

Email address: *

Contact Number *

Medications

Please include over- the- counter medications, vitamins, supplements and current prescription(s) .Please include strength, times per day, dosage and orders on how you take the medication.

List Medication(s) *

Allergies *

Medication Allergies *

Please list any medication(s) that you are allergic to and what happens if you take them.

Medical Problems

Problem and date it started *

Surgery- type and date *

Hospitalization(s) reason and date *

Family History

Mother

Father *

Sibling *

Other Family Member(s) -list relationship to you and medical problem *

Check here if you were adopted and you don't know your complete family history

Social History

Marital Status *

Children *

None

Biological

Step Children

Adopted

How many children do you have ? *

Please list all people living in your house. List name and releationhip *

Health Habits

How often do you smoke or chew tobacco or smoke a pipe *

Never

Daily

1-2 days per week

3-4 days per week

5-6 days per week

Other

Please let Dr.Yee know during your visit

How often do you use drugs? *

Never

Daily

1-2 days per week

3-4 days per week

5-6 days per week

Other

Please let Dr.Yee know during your visit

How often to you drink alcohol? *

Never

Daily

1-2 days per week

3-4 days per week

5-6 days per week

Other

How often do you excercise? *

Never

Daily

1-2 times per week

3-4 times per week

5-6 times per week

Other

Previous Doctor(s)

Name and Date

Check here if you have medical records with you

If you have anything that you would like to discuss but we haven't asked please list here *

Please list your history below *

How did you hear about our office? *

Screening for colon cancer *

Screenings completed within the last 12 months *

BMET

CMET

Glucose

Lipid panel

Mammogram

PSA

Other

None

* Required field