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Pre-appointment-Questionaire

The document is a pre-appointment questionnaire for patients to fill out before their visit, covering health goals, medical history, lifestyle habits, and current health concerns. It includes specific questions about conditions like high cholesterol, diabetes, and depression, as well as lifestyle factors such as alcohol consumption, exercise, and smoking. The form is designed to gather essential information to enhance patient care and can be customized for different practices.

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tjlottier
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18 views2 pages

Pre-appointment-Questionaire

The document is a pre-appointment questionnaire for patients to fill out before their visit, covering health goals, medical history, lifestyle habits, and current health concerns. It includes specific questions about conditions like high cholesterol, diabetes, and depression, as well as lifestyle factors such as alcohol consumption, exercise, and smoking. The form is designed to gather essential information to enhance patient care and can be customized for different practices.

Uploaded by

tjlottier
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Pre-appointment questionnaire

To be completed before or at the patient’s current visit


Patient name:
Date of birth: Appointment Date:

What do you hope to accomplish today?

Is there anything you would like to work on to improve your health?

Please respond if you have one of the following conditions:


High Cholesterol Problems with medication(s)?  No  Yes  N/A
Diabetes Problems with medication(s)?  No  Yes  N/A
Most recent home glucose readings:
High Blood Pressure Problems with medication(s)?  No  Yes  N/A
Most recent home blood pressure readings:
Depression Problems with medication(s)?  No  Yes  N/A
Any suicidal thoughts?  No  Yes  N/A

Have you been to the emergency room, hospital or any other provider since your last visit?
If yes, please explain:

Lifestyle

How often do you have a drink containing alcohol?


 Never  Monthly or less  2-4 times per month  2-3 times per week
 4 or more times per week
How many standard drinks containing alcohol do you have on a typical day?
 1 or 2  3 or 4  5 or 6  7 to 9  10 or more
How often do you have six or more drinks on one occasion?
 Never  Less than monthly  Monthly  Weekly  Daily or almost daily

Caffeine
Do you consume any caffeine?  No  Yes: How often? How much?

Exercise
Do you exercise?  No  Yes: How often? How long?

Smoking
Do you smoke?  No  Yes: How often? How much?

Birth control
Do you use any form of birth control?  No  Yes: What method?

Medication adherence
Do you have trouble taking any of your medications?  No  Yes: Describe.

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Copyright 2015 American Medical Association. All rights reserved.
Lifestyle

Are there any changes to your family medical history? For example, if a family member has
received a new diagnosis, we can update your family history to reflect any changes since your last
visit.

Have you recently developed an allergy to any of your medications? If yes, please describe
below.

Do you have any end-of-life care plans or preferences? If yes, please bring a copy of relevant
documents to your upcoming visit (e.g., your advance directive, power of attorney and health care
proxy). If not, would you like to discuss your preferences?

Are you experiencing any of the following?


 Abdominal pain  Diarrhea  Headache  Runny nose
 Anxiety  Double vision  Heart palpitations  Shortness of breath
 Blood in stools  Ear pain  Heat/cold intolerance  Sore throat
 Bloody urine  Enlarged lymph nodes  Impotence  Sudden vision loss
 Breast mass  Excessive thirst  Irregular menses  Suicidal thoughts
 Bruising  Extreme fatigue  Joint pain  Vomiting
 Changing mole  Falling  Muscle weakness  Unusual bleeding
 Chest pain  Fever  Nausea  Weakness
 Constipation  Frequent urination  Numbness  Weight loss
 Cough  Hay fever  Painful urination  Wheezing
 Depression

Do you have any other concerns? If yes, please describe below.

Source: AMA. Practice transformation series: pre-visit planning. 2015.

Please note that this document can be modified to meet the needs of your practice. Practices may find
that emailing the form along with additional instructions and information to patients or posting it on a
patient portal prior to the visit is most effective.

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Copyright 2015 American Medical Association. All rights reserved.

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