About Us
Clinic
Physicians
Staff
Notice of Privacy Practices
Primary Care First & Medicare Shared Savings
Careers
Patient Portal
New Patient Inquiry
Patient Paperwork
Welcome to FPG
Demographics
Health History
Patient Health Questionnaire (PHQ-9)
Printable Forms
Medicare Wellness Form
Medical Minute
Satisfaction Survey
Family Physicians Group
About Us
Clinic
Physicians
Staff
Notice of Privacy Practices
Primary Care First & Medicare Shared Savings
Careers
Patient Portal
New Patient Inquiry
Patient Paperwork
Welcome to FPG
Demographics
Health History
Patient Health Questionnaire (PHQ-9)
Printable Forms
Medicare Wellness Form
Medical Minute
Satisfaction Survey
Patient Paperwork
Welcome to FPG
Demographics
Health History
Patient Health Questionnaire (PHQ-9)
Printable Forms
Medicare Wellness Form
Medicare Wellness Form
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Date of Visit
*
MM
DD
YYYY
Over the past 2 weeks, how often have you been bothered by any of the following problems:
1. Little interest or pleasure in doing things
*
Not at all
Several days
More than half the days
Nearly every day
2. Feeling down, depressed, or hopeless
*
Not at all
Several days
More than half the days
Nearly every day
3. Trouble falling or staying asleep, or sleeping too much
*
Not at all
Several days
More than half the days
Nearly every day
4. Feeling tired or having little energy
*
Not at all
Several days
More than half the days
Nearly every day
5. Poor appetite or overeating
*
Not at all
Several days
More than half the days
Nearly every day
6. 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
7. Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several days
More than half the days
Nearly every day
8. Moving or speaking so slowly that other people have noticed? Or the opposite- being so fidgety or restless that you have been moving a lot more than usual
*
Not at all
Several days
More than half the days
Nearly every day
9. 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
Fall Prevention Assessment:
Have you had a fall within the past 12 months?
*
Yes
No
If yes, did you suffer an injury?
Yes
No
Are you experiencing any difficulties with walking or balance?
*
Yes
No
Please list your current healthcare providers: (Therapists, Specialists, etc.)
*
Optometrist:
*
Dentist:
*
Have you had any recent immunizations? (Do not include shots given here)
*
Have you had any preventative tests done recently? (ie. Mammograms, Colonoscopy, Lab Tests)
*
Do you have a healthcare proxy?
*
How would you rate your general health?
*
Excellent
Very Good
Good
Fair
Poor
Do you have to strain or struggle to hear or understand conversations?
*
Yes
No
Do you have issues with bladder control or urine leakage?
*
Yes
No
Do you feel safe in your home?
*
Yes
No
Do you complete your personal activities of daily living? (ie. dressing, bathing, shopping & house keeping)
*
Yes
No
If no, what assistance do you require?
Once you submit this form, go to printable forms, select Medicare Wellness Forms, print only the Clock Drawing Task (last page), complete it and bring it to your appointment. If you can not print this form, it will be available at your appointment.
Thank you!