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

Medicare Wellness Survey (Medicare Required)

What is your age *

65-69

70-79

80 or older

Other (younger than 65)

What is your sex? *

During the past 4 weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad, or downhearted and blue? *

During the past 4 weeks, has your physical and emotional health limited your social activities with family, friends, neighbors, or groups? *

During the past 4 weeks, how much bodily pain have you generally had? *

During the past 4 weeks, was someone available to help you if you needed and wanted help? *

For example, if you felt nervous, lonely, or blue; got sick and had to stay in bed; needed someone to talk to; needed help with daily chores; or needed help taking care of yourself.

During the past 4 weeks, what was the hardest physical activity you could do for at least 2 minutes? *

Can you get to places out of walking distance without help? *

For example, can you travel alone on buses, taxis, or drive your own car?

Can you go shopping without someone's help? *

Can you prepare your own meals? *

Can you do housework without help? *

Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house? *

Can you handle your own money without help? *

During the past 4 weeks, how would you rate your health in general? *

How have things been going for you during the past 4 weeks? *

Are you having difficulties driving your car? *

Do you always fasten your seat belt when you are in a car? *

How often during the past 4 weeks have you been bothered by falling or feeling dizzy when standing up? *

How often during the past 4 weeks have you been bothered by sexual problems? *

How often during the past 4 weeks have you had trouble eating well? *

How often during the past 4 weeks have you been bothered by teeth or denture related problems? *

How often during the past 4 weeks have you been bothered by problems using the telephone? *

How often during the past 4 weeks have you been bothered by feeling tired or fatigued? *

Have you fallen 2 or more times in the past year? *

Are you afraid of falling? *

Are you a smoker? *

During the past 4 weeks, how many alcoholic beverages did you consume? *

Do you exercise for about 20 minutes three or more days a week? *

Have you been given any information to help you regarding hazards in your home that may hurt you? *

Have you been given any information to help you keep track of taking your medications? *

How often do you have trouble taking medicines the way you have been told to take them? *

How confident are you that you can control and manage most of your health problems? *

What is your race? *

White

Black of African American

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaskan Native

Hispanic or Latino

Other

Audit C-How often do you have a drink containing alcohol? *

If you have selected NEVER, you may skip the following two questions

Audit C-How many standard drinks containing alcohol do you have on a typical day?

Audit C-How often do you have six or more drinks on one occasion?

PHQ 9- Over the last 2 weeks, how often have you experienced little interest or pleasure in doing things: *

PHQ 9- Over the last 2 weeks, how often have you experienced feeling down, depressed, or hopeless: *

PHQ 9- Over the last 2 weeks, how often have you had trouble falling asleep, staying asleep, or sleeping too much: *

PHQ 9-Over the last 2 weeks, how often have you experienced feeling tired or had little energy: *

PHQ 9-Over the last 2 weeks how often have you experienced poor appetite or overeating? *

PHQ 9-Over the last 2 weeks how often have you felt bad about yourself, or felt as if you were a failure, or if you have let yourself or your family down? *

PHQ 9-Over the last 2 weeks have you had trouble concentrating on things such as reading the newspaper or watching television? *

PHQ 9-Over the last 2 weeks have you experienced yourself moving or speaking so slowly that other people could have noticed? Or the opposite, being that you are fidgety or restless? *

PHQ 9-Over the last 2 weeks have you had thoughts that you would be better off dead or had thoughts of hurting yourself in anyway? *

* Required field