Jump to Content
Flagstaff Family Physicians, P.C -Robert Yee, M.D.
Home
Forms
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
Physical Exam Form Required
Do you have any concerns?
*
Yes
No
Other- Please let staff know when checking in for your appointment
What tests have you had in the past 12 months?
Bmet
Cmet
Colonoscopy
Lipid
Mammogram
PSA
Tsh
Other
None
Do you take medications prescribed by another provider?
*
-- Please Select --
No
Yes .Please let staff know when checking in for your appointment
Have you had a well woman or a well man exam in the past 12 months?
*
-- Please Select --
No
Yes
Have you had an influenza vaccine this year?
*
-- Please Select --
No
Yes
Please check mark applicable statements
I check my blood pressure daily
I check my weight regularly
I eat a healthy diet
I exercise regularly
Do you use tobacco?
*
-- Please Select --
No
Yes
Depression Screening
Over the past 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure doing things
-- Please Select --
0 Not At All
1 Several Days
2 More than Half of the Days
3 Nearly Every Day
Feeling down, depressed or hopeless
-- Please Select --
0 Not At All
1 Several Days
2 More than Half of the Days
3 Nearly Every Day
Trouble falling asleep, or sleeping too much
-- Please Select --
0 Not At All
1 Several Days
2 More than Half of the Days
3 Nearly Every Day
Poor Appetite or overeating
-- Please Select --
0 Not At All
1 Several Days
2 More than Half of the Days
3 Nearly Every Day
Feeling bad about yourself- or that you are a failure or have let yourself or your family down
-- Please Select --
0 Not At All
1 Several Days
2 More than Half of the Days
3 Nearly Every Day
Trouble concentrating on things, such as reading the newspaper or watching TV
-- Please Select --
0 Not At All
1 Several Days
2 More than Half of the Days
3 Nearly Every Day
Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless other people could notice
-- Please Select --
0 Not At All
1 Several Days
2 More than Half of the Days
3 Nearly Every Day
Thouths that you would better off dead or thoughts of hurting yourself in some way
-- Please Select --
0 Not At All
1 Several Days
2 More than Half of the Days
3 Nearly Every Day
Total Score:
*
(please add all 9 questions)
Alcohol Screening Audit-C
Do you drink alcohol? If No, please skip the next 2 questions
*
-- Please Select --
No
Yes
How often do you have a drink containing alcohol?
-- Please Select --
Monthly or less
2-4 times per month
2-3 times per week
4 or more times per week
How often do you have six drinks or more on one occasion?
-- Please Select --
Never
Less than monthly
Monthly
Weekly
Weekends
Daily or almost daily
Allergies
Please list your allergies
*
-- Please Select --
None
Ace inhibitors
Codeine
Penicillins
Sulfas
Other- Please let staff know when checking in for your appointment
Date
*
Electronic Signature
*
-- Please Select --
Yes
No
* Required field
Submit Form
