PATIENT INFORMATION
First Name:*
Last Name:*
DOB:*
Sex:*
Marital Status:*
Email Address:*
Address:
City:
State:
Zip:*
Home Phone:*
Cellphone:
FAMILY CONTACT
Name:*
Relationship:*
Home Phone:
Cellphone:
Work Phone:
FIRST APPOINTMENT THOUGHTS
Was the initial session a positive experience for the patient? Yes No
If yes, how so?:
If no, how so?:
Where the suggestions from the initial session utilized and were there any response from it?
As a result of the initial session, have your long-term health goals changed in any way? Added goals you did not have before? Or taken away goals you feel may not be reachable?
Medications you are on (please list Names, Dosage (mg.) , and how may times you take per day (ie: Diovan 80 mg. 1 take 2 times per day) :*
PHYSICIAN INFORMATION
Are you currently under a Physician’s Care?* Yes No
If so, for what?:Please list all the physicians (primary, cardiologist, gastroenterologist, allergist) and what they are treating you for. Note any that apply, please.
MEMORY RESOURCES
Was the patient able to utilize any of our Memory Resources? Yes No
If so, was it enjoyable / did the patient engaged with it?
Do you have any ideas for further content you may feel will help impact the patient that we do not currently offer?(this will help with all of our patients and we hope to make certain that every patient is engaged with the memory resources) .