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Microsoft Word - 22.27 KB]
Patient Name Date
1. What would you like to talk to the doctor about today?
2. How would you describe your health since your last visit?
___ Excellent ___ Very Good ___ Good ___ Fair ___ Poor
3. Have you been in the hospital or been to the Emergency Room since your last visit?
___ Yes ___ No.
4. Have you seen any other doctors since your last visit?
___ Yes ___ No.
5. Have your medicines changed since your last visit?
___ Yes ___ No.
6. Have you been exercising?
___ Yes ___ No.
7. Have you been hit, pushed, shoved, kicked, or threatened by someone important to you?
___ Yes ___ No.
8. During the past 2 weeks, have you often been bothered by having little interest or pleasure in doing things?
___ Yes ___ No.
9. During the past 2 weeks, have you often been bothered by feeling down, depressed, or hopeless?
___ Yes ___ No.
