Annual Screening Assessments

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This is an electronic version of all of our routine screening assessments. These should be completed and submitted prior to your first appointment at Pohala. They are then to be completed every 1 calendar year thereafter. It will take approximately 10-20 minutes to take.

Note: This must be completed no earlier than 14 calendar days prior to your appointment, and no later than the morning of.

The answers you provide here are private, and will be used only in regards to your healthcare. These answers are protected under HIPAA.

Email *

What is your full legal name? *

What is your date of birth? *

YYYY

Who is your health insurance provider? (Example BCBS, CareOregon, Medicare, United). *

Clear form

Never submit passwords through Google Forms.

This form was created inside of Pohala Clinic. Report Abuse

Forms