QPC New Patient - Page 3

Quick Primary Care

New Patient Information - Page 3 of 9

Patient Information (Continued...)

Do you use a sleep apnea (CPAP/BIPAP) machine?

Do you have any of the following, please check all that apply:

Do you live with anyone or alone?

Mammogram

Breast Exam

Bone Density

Colonoscopy

Eye exam

PAP Smear

PSA

Prostate Exam

Review the following list and give the date of the last time you had the tests and where they were performed

Influenza (Flu) Vaccine

Shingles (Zoster) Vaccine

Tetanus (Tdap/Td)

Pneumonia (Prevnar/Pneumovax) Vaccine

FEMALES ONLY

Pregnancy

Menses

Signature