ADULT PREVENTIVE PHYSICAL EXAM INSTRUCTIONS
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1 ADULT PREVENTIVE PHYSICAL EXAM INSTRUCTIONS Your provider has given you an extended appointment time for your preventive exam. If you are unable to make your appointment, please call at least 24 hours in advance at Thank you for your cooperation. What is included in your preventive exam (annual physical): Review your past medical, social, and family history Complete physical exam Discuss screening tests or services you may be due for Medication review Education/counseling on how to improve your health and prevent disease What is not included in a preventive exam (annual physical): Monitoring a problem or condition you already have, including lab tests and medication refills Treatment of problems found during the preventive exam Treating an acute illness (cold, flu, bad cough, back pain, etc.) If any of these types of services are provided, you may owe a copay.
2 SEE REVERSE SIDE FOR MORE INFORMATION FASTING INSTRUCTIONS Attention Patients who are 65 Years and Older All preventive physical exams, for patients who are 65 years and older, now include Medicare s wellness visit components- also known as the Welcome to Medicare Exam (IPPE), Initial Wellness Visit (IWV) or Annual Wellness Visit (AWV). The Medicare Wellness portion of the visit is at no cost to you. We look forward to seeing you. If you have any questions, please do not hesitate to
3 MULTICARE ASSOCIATES Date of Appointment: Adult Male Preventative Physical Exam Name: Date of Birth: Provider: PLEASE COMPLETE ALL PAGES Medications-Please list all medications you are taking: Include dosage and frequency of each as well as vitamins, over-the-counter and herbal products: Allergies: Past Medical History (check any condition or disease you ve had) Allergies; What type Gallbladder disease Anemia GERD Angina Headache, migraine Anxiety Heart disease Arthritis Heart valve disorder Asthma Hepatitis/liver disease Atrial fibrillation Hypertension Blood Clots: Where Irritable bowel disease Cancer: Type Myocardial Infarction (heart attack) Cardiac arrhythmia (irregular heart rate) Osteoporosis MCA /25//2014 Latex Allergy: Yes No IMPORTANT INFORMATION As part of your physical, it is important that you inform the provider about any concerns and problems that you have. Please be aware, if during your physical exam, any of those concerns or problems require treatment (such as x-rays, tests, or you are given a prescription or advice) you may be charged for an office visit in addition to the physical charge. COPD Renal (kidney) disease Coronary (heart) artery disease Type Seizure disorder Depression Thyroid disease Diabetes: Type 1 OR Type 2 Other: Elevated Lipids (high cholesterol): Type Past Surgical History Year Year Year Angioplasty Gastric bypass Other: Angio w/ stent Hernia repair Appendix removed Hip replacement Arthroscopy of knee Knee replacement Back surgery LASIK Coronary artery bypass Liver biopsy Carpal tunnel release Surgery for broken bones Cataract extraction Pacemaker Gallbladder removed Small bowel resection Colon resection Thyroid removed Colostomy Tonsils removed
4 Family History: Page 2 Please use the relationship abbreviations shown below to identify who in your family has the disease or health problem M= Mother F= Father S= Sister B= Brother MGM= Maternal grandmother (your mother s mother) MGF= Grandfather (your mother s father) PGM= Paternal grandmother (your father s mother) PGF= Paternal grandfather (your father s father) Relationship What Cause of Relationship What Cause of age Death age Death ADD/ADHD High cholesterol* Alcoholism Genetic disease Allergies* Hearing problems Alzheimer s High blood pressure Arthritis* Irritable bowel disease Asthma Learning disability Blood disorder Mental illness Cancer-colon Migraines Cancer-prostate Obesity Cancer-Other** Osteoporosis Heart disease* Peripheral vascular disease Depression Renal/kidney disease Developmental delay Seizures Diabetes* Stroke Eczema Thyroid disorder **If you have a history of other types of cancer in your family, please list them below along with the family member s relationship to you: Preventive Health History Please enter the date you last had any of the following: Cholesterol test Zostavax (shingles vaccine) Colonoscopy PSA (prostate cancer screening) Tetanus Pneumovax (pneumonia vaccine) MCA /25//2014
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Surgery Health Survey Name: Social Security Number: Date of Birth: Please tell us which physician(s) we should contact regarding your visit: REFERRING PHYSICIAN Name: Address: PRIMARY CARE PHSYICIAN Name:
PLEASE PRINT LEGIBLY
Patient Information PLEASE PRINT LEGIBLY Patients Name: Date of Birth: Sex: Patients Address: City: State: Zip: Home Phone: Cell: Work: Email: SSN: Employer: Occupation: Marital Status: Employed: Full
Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD
Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine