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
DOB
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SCREENERS
Tobacco Screening:
Do you currently smoke or use smokeless tobacco?
Clear selection
If yes, what do you use?
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How much do you use per day?
Are you interested in quitting?
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Depression Screening
Over the last 2 weeks, have you had little interest in doing things?
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Over the last 2 weeks, did you feel down, depressed, and hopeless?
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Anxiety Screening:
Over the last 2 weeks, did you feel nervous, anxious, or on edge?
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Over the last 2 weeks, were you not able to stop/control worrying?
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Medication Adherence:
Are there any prescribed medications that you need a refill for?
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Are there any prescribed medications that you stopped taking?
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Has your physician gone through your medication list with you this calendar year?
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Cancer Prevention Screenings
Colorectal Cancer: If you are over 50, have you had a colonoscopy?
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If yes, when (month, year)?
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If no, have you completed an FOBT (home fecal test)?
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If yes to FOBT, when (month, year)?
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Breast Cancer: If you are a woman over 40, have you had a mammogram?
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If yes, when (month, year)?
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Cervical Cancer: Women 21-65, have you had a PAP smear?
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If yes, when was your last PAP smear?
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Adults Over 65 Years Old
Advanced Care Directive
Do you have an Advanced Healthcare Directive or Living will?
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If yes, do we have a copy of it in your medical record?
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If yes, when did you last review your ACP?
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Fall Screening
Have you had 2 or more falls within the last 12 months?
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Have you had a fall with injury?
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If so, when and what was the injury?
Do you have problems with gait or balance?
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Functional Status Assessment: (check all of the following that you can do independently).
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