ST MICHAEL MEDICAL CLINIC PA

1. Patient Full Name (First, Middle, Last Name): ___ * 2. Date of birth MM/DD/YY: ___ * 3. Current medical condition: ___ * 4. Additional current medical conditions: ___ 5. Past Surgical History: ___ * 6. Additional information on past surgery and past medical history: ___ 7. List of current doctors/providers (specialty). ___ 8. Family's health history: ___ * 9. Additional information on family's health history: ___ 10. Daily Aspirin Assessment: ___ * 11. End of Life Planning: ___ * 12. Motor Vehicle Safety: ___ * 13. Drug Use screening: ___ * 14. Alcohol Misuse Screening: ___ * 15. Tobacco Assessment: ___ * 16a. # of pk per day: __ . # of year use tobacco:__ Year quit: __ 17. Hearing Assessment: ___ 18. Sexual infections Assessment: ___ * 19. DAILY LIVING ASSESSMENT: ___ * 20. Eye Assessment: ___ 21. Date Flu Influenza shot MM/DD/YY: ___ 22a. Date retinal eye exam, note if eye dilated, and result: ___ 22b. Dr Name, and tel#. Note if Optometrist or ophthalmologist. Authorized StMichael to get eye exam report. 23a. Date Pap cervial smear, Dr Name, specialty, Tel#, and result: ___ 23b. Date of total hysterectomy removed cervix , Dr Name, specialty, and tel#. 24. Date mammogram, Dr Name, Tel#, and result: ___ 25a. Date Colonoscopy, Dr Name, specialty, Tel#, and result: ___ 25b. Date Cologuard and result: ___ 25c. Other Colon cancer screening test. Type of Test, Date, and result: ___ 26. During the past 4 weeks, ___ * 27. During the past 4 weeks, ___ * 28. During the past 4 weeks, ___ * 29. During the past 4 weeks, ___ * 30. Exercise assessment: ___ * 31. Meal/Diet Assessment: ___ 32. During the past 4 weeks, ___ 33. During the past 4 weeks, ___ 34. Mental health assessment: ___ 35. Accident Assessment : ___ 36. Fall Risk assessment: ___ * 37. Fall Assessment: ___ 38. -- Ambulatory aid (used during gait): ___ 39. -- Intravenous therapy / saline lock (infusion of liquid substances directly into a vein): ___ 40. -- Mental status (Pt's own assessment of ability to walk): ___ 41. -- 2nd medical condition/diagnosis (of any kind listed in medical chart): ___ 42. -- Gait (walking characteristics / abnormality): ___ 43. -- Total score:___ (<25 points = NO Risk; <51 points = Moderate; 51+= HIGH) 44. If at risk for fall then need to discuss with Dr. preventative plan, which goal is to increase: balance, strength, gait.

45. Depression Screening =================

45a. Over the last 2 weeks, how often have you been bothered by - Little interest or pleasure in doing things? * 45b. Over the last 2 weeks, how often have you been bothered by - Feeling down, depressed, irritable, or hopeless? * 45c. Over the last 2 weeks, how often have you been bothered by - Trouble falling asleep, staying asleep, or sleeping too much? * 45d. Over the last 2 weeks, how often have you been bothered by - Feeling tired, or having little energy? * 45e. Over the last 2 weeks, how often have you been bothered by - Poor appetite, weight loss, or overeating? * 45f. Over the last 2 weeks, how often have you been bothered by - Feeling bad about yourself or feeling that you are a failure, or that you have let yourself or your family down? * 45g. Over the last 2 weeks, how often have you been bothered by - Trouble concentrating on things like school work, reading, or watching TV? * 45h. Over the last 2 weeks, how often have you been bothered by - Moving or speaking so slowly that other people could have noticed? 45h. Or the opposite - being so fidgety or restless that you were moving around a lot more than usual? 45i. Over the last 2 weeks, how often have you been bothered by - Thoughts that you would be better off dead, or of hurting yourself in some way? * 45j. Over the last 2 weeks, how often have you been bothered by - If you selected several days to nearly every day on any problems, 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? * Signed by Patient/Guardian name and date: ___