Presken Family Care - Annual Wellness Exam - How to STAY HEALTHY and PREVENT DISEASE

Your First Name

Your Last Name

Your Date of Birth

COVID SCREENING QUESTIONS

In the past 14 days have you had any of the following: Check all that apply

Temperature greater than 99.0 degrees

Cough

Sore throat

Diarrhea

Trouble breathing

Exposure to someone with coronavirus symptoms or who has tested positive

Loss of smell

Loss of taste

None of the above

If you have received your 1st, 2nd, or booster Covid vaccine, please indicate which type(s) you received (Pfizer/Moderna/J&J) and when you received the shot(s).

LIFESTYLE CHOICES

How often do you smoke/chew tobacco?

Come talk to me when you are ready to quit.

How much alcohol do you have daily?

> 2 drinks per week for women increases breast cancer risk.

How often do you vape?

Don't!

How often do you use marijuana?

Don't drive within 4 hours of using marijuana.

If you have marijuana products, are they locked in a box away from children and pets?

Keep all marijuana products (including edibles) in a secure location that children and pets cannot access.

How often do you use non-medical drugs?

Many herbs/supplements have not been tested for safety.

How much caffeine do you have daily?

2 cups a day is good for your liver (but can worsen reflux and blood pressure!)

How often do you exercise?

45 minutes/day keeps the weight off!

SCREENING TESTS (how many years ago roughly) and OTHER QUESTIONS

Have you had any trouble controlling your ability to go to the bathroom in the past year?

Last screening test for diabetes and cholesterol?

Recommended yearly.

Last colonoscopy (>45 years old)

Typically every 5-10 years.

Last pap smear (women 25 years or older)

Typically if paps have been normal: age 25-29 every 3 years; 30-64 every 5 years.

Who do you go to for your pap smears (women 25 years or older)

Last mammogram (women >40 years)

Typically every year.

Last bone mineral density (women >65 years)

Recommended every 2 years.

If you smoke or have every smoked: Last CT scan (55-77 years old or quit <15 years ago)

If you smoke or have every smoked: Last ultrasound for abdominal aneurysm (men 55-75 years old)

Recommended one time.

If you have diabetes, when was your last eye exam? Who performed the exam? Were the results of the eye exam normal or not normal?

VACCINES (How many years ago roughly?)

Did you get your flu shot this season?

Date of last tetanus/pertussis vaccine (not covered by Medicare - $53 cost)

Recommended every 10 years.

Did you get the new shingles vaccine (check with plan to see if it is covered - $160 cost per dose)?

If >65 years old, date of 1st pneumonia vaccine (Prevnar)

If >65 years old, date of 2nd pneumonia vaccine (Pneumovax)

SAFETY SCREEN

If you are >65 years old, do you have any of these in your home:

Hallways clear of rugs

Bathroom grab bars

Handrails on the stairs

Good lighting

NON-MEDICAL FACTORS THAT AFFECT YOUR HEALTH

You can find resources to help on my website PreskenFamilyCare.com

I am so glad that the insurance company you chose has allowed you to participate in this Annual Wellness Exam.

Please schedule a separate visit to discuss any issues we are not able to address during the wellness visits, due to the limits of your chosen insurance company.

I understand that after submitting this form a staff member will contact me to schedule my wellness exam.

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