Jump to Content

Available Forms


ANNUAL WELLNESS (Under Age 65) - (For Established Patients Only - Do Not Submit this form if you are a NEW Patient)

Do NOT submit this form unless you are an ESTABLISHED PATIENT who has an upcoming appointment for an Annual Wellness Exam (Physical) AND you are UNDER AGE 65. NOTE: NEW Patients should NOT use this form and should only submit the forms labeled "NEW PATIENT"

(such as new illnesses, surgeries, new medication allergies or intolerances, etc)
(such as increased stress, new job, home, relationship, children, ill relatives, etc)
(If any blood relative has had cancer, please list their relation to you, the type of cancer & how old they were when diagnosed)
(Check all that apply)
(Check all that apply)

If you are a former smoker, please answer the following questions related to your smoking history:




Most healthy patients would like to be treated aggressively (such as CPR, respirator, ICU, etc) if they had a potentially curable condition.


If you were unable to make your own healthcare decisions (for instance, you were in a coma from a car accident), whom would you want to be asked about what your healthcare wishes would be? Name one primary person and one alternate.


Annual Health Screening - PHQ-9

OVER THE LAST 2 WEEKS, how often have you been bothered by any of the following problems?


Annual Health Screening - AUDIT C



* Required field