Complete Physical Exam Questionnaire

Name*

First Last

Date

Please list the date of your last colonoscopy and where it was performed:

Please list the date of your last bone density scan (DEXA)and where it was performed:

Please list the date of your last dilated/retinal eye exam and where it was performed:

Please list the date of your last Tetanus vaccine:

Please list the date of your last Pneumonia vaccine:

Please list the date of your last Influenza vaccine:

Please list the date of your last Shingles vaccine:

Please list the date of your last mammogram (women only) and where it was performed:

Please list the date of your last pap smear (women only) and where it was performed:

Please list the date of your last menstrual period (women only):

Please list any updates to your health history since your last visit (surgeries, new diagnosis, etc):

Please list any other providers or specialists your see:

Please list any family or personal history of cancer including type and age of occurence:

Example: Breast: mother, 56. Colon: paternal grandfather, 78.

Please list any Emergency room visits or hospitalizations in the past year:

Please list any changes to your medications or supplements this year:

Do you have any skin spots or moles you would like evaluated?

Yes
No

Have you been told or noticed that you stop breathing or struggle to breathe in your sleep?:

Yes
No

How often do you exercise?

How would you rate your diet?

How often do you smoke?

How often do you drink alcohol?

How often do you use marijuana?

How often do you use illicit drugs?

How would you rate your stress level?

How would you rate your sleep?

Over the past several weeks, how often have you felt little interest or pleasure in doing things?

Over the past several weeks, how often have you felt down, depressed, or hopeless?

Over the past several weeks, how often have you had trouble falling asleep, staying asleep, or sleeping too much?

Over the past several weeks, how often have you felt tired or with too little energy?

Over the past several weeks, how often have you had a poor appetite or overate?

Over the past several weeks, how often have you felt bad about yourself (or that you are a failure or have let your family down)?

Over the past severeal weeks, how often have you had poor concentration on things such as reading or watching television?

Over the past several weeks, how often have you noticed you are moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual?

Over the past several weeks, how often have you noticed thoughts that you would be better off dead or hurting yourself in some way?

Do you have a history of falling or feel you are at risk for falling?

Yes
No

Do you experience dizziness and/or have trouble keeping your balance?

Yes
No

Do you have any vision or hearing problems?

Yes
No

Do you make frequent or hurried trips to the bathroom?

Yes
No

Do you notice increasing difficulty remembering important details or events?

Yes
No

Links

Locations

info@altitudemedicine.com

(303) 730-2167

(303) 996-4820

The Altitude Difference

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