unity point health

Patien Form





  • When Was Your Last Check-Up?

    Unknown


    Prefered Pronouns

    If Other:

    Gender

    If Other:


    If Female: Are You Pregnant? Planning To Be Soon? Or Recently? If Yes to Any, Explain:

    N/A

    Are You On Birth Control? No
    Yes
    If Yes, What Kind?:


    Last Breast Exam? (only if 21 or over)


    Race White
    Black
    Asian
    Latino
    Other

    Age

    Height

    Weight

    Blood Pleasure

    Heart Rate

    Temperature


    Do You Smoke? No
    Yes
    If Yes, What Do You Smoke? How often?:


    Do You Drink? No
    Yes
    If Yes, How Many and How Often?:


    How Many Hours of Sleep Do You Get Every Night?

    Have You Recived All of Your Immunizations(Shots)? Yes
    No
    If No, Explain:


    Do You Have Any Allergies? No
    Yes
    If Yes, Explain:


    Any Current Medication and/or Prescriptions? No
    Yes
    If Yes, Explain:


    Family Medical History? No
    Yes
    If Yes, Explain:


    Reason for Visit?



    Does Anything Hurt? No
    Yes
    If Yes, On A Scale From 1-10 How Bad Is It?

    Has This Happened Before? No
    Yes
    If Yes, Explain:

    When Was the Last Time You Ate?

    When Was Your Last Surgery? If Any?
    N/A
    How Often Do You Excersize?


    Check-Up Tired
    Mood Swings
    Lack of Motivation
    Anxious
    Trouble Paying Attention
    Stressed
    Hallucination and/or Dillutions
    Fatigue
    History of Anxiety and/or Depression?

    Relationship Are You In A Relationship? No
    Yes

    If Yes:

    Do You Feel Safe? Yes
    No
    If No, Explain:


    Are You Being Forced To Do Anything You Don't Want To Do? No
    Yes
    If Yes, Explain:



    Sexual Activity How Many Partners Have You Had?
    N/A

    If Yes:

    Any STD's and/or Sex Related Infections? No
    Yes
    If Yes, Explain:


    Are You Being Forced To Do Anything You Don't Want To Do? No
    Yes
    If Yes, Explain:



    Check-up Lungs

    Heart

    Reflexes

    Diet

    Digestion


    Any Questions?
    N/A