Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Please list any wellness goals and/or concerns:
*
Have you been seen in an urgent care, ER, or hospital since last seen?
*
Yes
No
Please list any current healthcare providers (dermatologist, cardiologist, pulmonologist etc.):
*
What is your preferred pharmacy?
*
What is your assessment of your general health?
*
Poor
Fair
Good
Excellent
In general, how satisfied are you with your life?
*
Not satisfied
Somewhat satisfied
Satisfied
Very satisfied
How many days a week do you usually exercise?
*
On days when you exercise, for how long do you exercise?
*
How intense is your typical exercise?
*
Light (like stretching, slow walking)
Moderate (like jogging or swimming)
Heavy (like fast running, stairs)
Do you currently smoke cigarettes?
*
Yes
No
Are you a former smoker?
*
Yes
No
If you quit smoking, was it in the past 15 years?
Yes
No
For current or past smokers, calculate your pack years by taking the number of years you smoked x packs per day. For example, if you smoked for 30 years at 1/2 pack per day, your pack years=15. If you smoked for 10 years at 2 packs per day, your pack years=20. Have you smoked 20 pack years or more?
Yes
No
Do you use other tobacco products?
*
Yes
No
If you use other tobacco products, what do you use?
Do you ever drink alcoholic beverages?
*
Yes
No
How many drinks do you average in a week?
*
Do you ever drink more than 2 drinks in a day?
*
Yes
No
Do you ever drive under the influence of alcohol or drugs?
*
Yes
No
Do you ever ride in a car with a person who is under the influence of alcohol or drugs?
*
Yes
No
Do you use any recreational drugs?
*
Yes
No
In a typical day do you consume more than 2 caffeinated beverages?
*
Yes
No
Do you consume energy drinks?
*
Yes
No
On a typical day, approximately how many servings of vegetables do you eat?
*
On a typical day, approximately how many servings of breads, pasta, rice, chips, cracker, and sweets do you eat?
*
On a typical day, approximately how many servings of protein do you eat?
*
Do you typically protect yourself from the sun when you are outdoors?
*
Yes
No
Sometimes
Do you always wear a seat belt while riding in the car?
*
Yes
No
When was your most recent blood pressure check?
*
What was your blood pressure?
*
How many hours of sleep do you get each night?
*
How many hours of sleep does your body require each night ideally?
*
Do you have any nipple discharge or new or enlarging breast lumps?
Yes
No
Have you ever been diagnosed with breast, ovarian, tubal, or peritoneal cancer?
Yes
No
Has your mother, father, sibling, or child been diagnosed with breast, ovarian, tubal, or peritoneal cancer?
Yes
No
Do you have Ashkenazi Jewish ancestry in your family?
Yes
No
Have you or a family member ever been diagnosed with a BRCA, PTEN, or TP53 gene mutation?
Yes
No
Have you ever had a breast biopsy?
Yes
No
Did you receive chest radiation between the ages of 10 and 30?
Yes
No
Do you perform routine self-breast exams? If you do not perform monthly self breast exams, start now. It can be a life-saving habit.
Yes
No
A breast cancer feels hard like a rock, not soft, and often irregular/asymmetrical as opposed to being smooth and fairly symmetrical like a grape. Do you have any lumps that you are concerned about?
Yes
No
Have you had your Hepatitis B vaccines?
*
Yes
No
Unknown
If yes, what year?
If female, date of last PAP smear and HPV test:
If female, have you had a positive HPV test in the past 10 years?
Yes
No
If female, hysterectomy with cervix removed?
Yes
No
Any new sexual partners in the last year?
*
Yes
No
Birth control method used:
*
STD protection used?
*
Yes
No
Have you had an eye exam in the last year?
*
Yes
No
Have you had a dental exam in the last year?
*
Yes
No
Do you undergo annual skin exams with a dermatologist?
*
Yes
No
Number of hours of screen time per day on average that is not related to school or work (e.g., gaming, TV, social media)?
*
Do you have friends and family that you enjoy being with?
*
Yes
No
Do you have someone that you contact in the event of an emergency?
*
Yes
No
Do you feel safe in all your relationships?
*
Yes
No
Little interest or pleasure in doing things:
*
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed or hopeless:
*
Not at all
Several days
More than half the days
Nearly every day
Trouble falling asleep, staying asleep or sleeping too much:
*
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy:
*
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating:
*
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself - or that you are a failure or have let yourself or your family down:
*
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching TV:
*
Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual:
*
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
*
Not at all
Several days
More than half the days
Nearly every day
If you checked off 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?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Feeling nervous, anxious, or on edge:
*
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying:
*
Not at all
Several days
More than half the days
Nearly every day
Worrying too much about different things:
*
Not at all
Several days
More than half the days
Nearly every day
Trouble relaxing:
*
Not at all
Several days
More than half the days
Nearly every day
Being so restless that it's hard to sit still:
*
Not at all
Several days
More than half the days
Nearly every day
Becoming easily annoyed or irritable:
*
Not at all
Several days
More than half the days
Nearly every day
Feeling afraid, as if something awful might happen:
*
Not at all
Several days
More than half the days
Nearly every day
Have you ever felt you should cut down on your drinking?
*
Yes
No
Have people annoyed you by criticizing your drinking?
*
Yes
No
Have you ever felt bad or guilty about your drinking?
*
Yes
No
Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
*
Yes
No
Do you have an Advanced Directive regarding end of life planning? If yes, please send us a copy.
*
Yes
No
