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QCPQ Annual Patient Intake Form
Please fill in all sections to the best of your ability. This will help our providers ensure you get all of the necessary preventative care.
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Name
Your answer
DOB
MM
/
DD
/
YYYY
SCREENERS
Tobacco Screening:
Do you currently smoke or use smokeless tobacco?
No
Yes
Clear selection
If yes, what do you use?
Cigarettes
Pipe
Smokeless
Clear selection
How much do you use per day?
Your answer
Are you interested in quitting?
No
Yes
Clear selection
Depression Screening
Over the last 2 weeks, have you had little interest in doing things?
Not at all
Several days
More than half the days
Nearly every day
Clear selection
Over the last 2 weeks, did you feel down, depressed, and hopeless?
Not at all
Several days
More than half the days
Nearly every day
Clear selection
Anxiety Screening:
Over the last 2 weeks, did you feel nervous, anxious, or on edge?
Not at all
Several days
More than half the days
Nearly every day
Clear selection
Over the last 2 weeks, were you not able to stop/control worrying?
Not at all
Several days
More than half the days
Nearly every day
Clear selection
Medication Adherence:
Are there any prescribed medications that you need a refill for?
No
Yes
Clear selection
Are there any prescribed medications that you stopped taking?
No
Yes
Clear selection
Has your physician gone through your medication list with you this calendar year?
No
Yes
Clear selection
Cancer Prevention Screenings
Colorectal Cancer: If you are over 50, have you had a colonoscopy?
No
Yes
Clear selection
If yes, when (month, year)?
MM
/
DD
/
YYYY
If no, have you completed an FOBT (home fecal test)?
No
Yes
Clear selection
If yes to FOBT, when (month, year)?
MM
/
DD
/
YYYY
Breast Cancer: If you are a woman over 40, have you had a mammogram?
No
Yes
Clear selection
If yes, when (month, year)?
MM
/
DD
/
YYYY
Cervical Cancer: Women 21-65, have you had a PAP smear?
No
Yes
Clear selection
If yes, when was your last PAP smear?
MM
/
DD
/
YYYY
Adults Over 65 Years Old
Advanced Care Directive
Do you have an Advanced Healthcare Directive or Living will?
No
Yes
Clear selection
If yes, do we have a copy of it in your medical record?
No
Yes
Clear selection
If yes, when did you last review your ACP?
MM
/
DD
/
YYYY
Fall Screening
Have you had 2 or more falls within the last 12 months?
No
Yes
Clear selection
Have you had a fall with injury?
No
Yes
Clear selection
If so, when and what was the injury?
Your answer
Do you have problems with gait or balance?
No
Yes
Clear selection
Functional Status Assessment: (check all of the following that you can do independently).
Bathing
Dressing
Eating
Getting out of bed
Toileting
Walking
Grocery shopping
Driving
Phone use
Preparing meals
Housework
Laundry
Taking medication
Handling finances
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