2208 University Blvd Suite 102
Birmingham, AL 35233
Login/Register
Pay Bill
$
0.00
0
Cart
Services
Long COVID Care
Vaccine Injury Care
General Medical Appointment
Patients
Events
Services
Long COVID Care
Vaccine Injury Care
General Medical Appointment
Patients
Events
Services
Patients
Events
About
Blog
Contact
Services
Patients
Events
About
Blog
Contact
About
Blog
Contact
About
Blog
Contact
Lifestyle Assessment Form
Step
1
of
12
8%
Patient Name
First
Last
Date Of Birth
MM slash DD slash YYYY
Current overall LEVEL OF HEALTH
(Required)
1
2
3
4
5
6
7
8
9
10
Please rank the top 3 areas you would like to improve with.
(Required)
Sleep
Weight Management
Nutrition
Exercise
Purpose & Connection
Mental Health
Substance Use
How IMPORTANT is it for you to make the change you ranked as the #1 most motivated topic area to address?
(Required)
1
2
3
4
5
6
7
8
9
10
How CONFIDENT are you regarding your ability to make the change you ranked as the #1 most motivated topic area to address?
(Required)
1
2
3
4
5
6
7
8
9
10
How IMPORTANT is it for you to make the change you ranked as the #2 most motivated topic area to address?
(Required)
1
2
3
4
5
6
7
8
9
10
How CONFIDENT are you regarding your ability to make the change you ranked as the #2 most motivated topic area to address?
(Required)
1
2
3
4
5
6
7
8
9
10
How IMPORTANT is it for you to make the change you ranked as the #3 most motivated topic area to address?
(Required)
1
2
3
4
5
6
7
8
9
10
How CONFIDENT are you regarding your ability to make the change you ranked as the #3 most motivated topic area to address?
(Required)
1
2
3
4
5
6
7
8
9
10
What would you like to gain from this lifestyle visit? Check all that apply.
(Required)
More medical/scientific knowledge
Practical health tips
Other
Accountability
Personalized plan
Please specify
Please answer based on your sleeping patterns OVER the LAST TWO WEEKS
1=Never 2=Seldom 3=Sometimes 4=Often 5=Always
How often have you had difficulty staying awake during routine tasks?
(Required)
1
2
3
4
5
How often have you had difficulty staying awake while driving?
(Required)
1
2
3
4
5
How often have you felt fatigued or needed to nap during the day?
(Required)
1
2
3
4
5
How often has it taken you more than 30 minutes to fall asleep at night?
(Required)
1
2
3
4
5
How often have you woken up at night?
(Required)
1
2
3
4
5
How often have you unintentionally woken up early in the morning?
(Required)
1
2
3
4
5
How often do you look at a screen within 2 hours of sleeping (i.e. TV, computer, iPad, or Phone)?
(Required)
1
2
3
4
5
How often have your legs or arms jerked during sleep?
(Required)
1
2
3
4
5
How often have you experienced “creeping” or “crawling” feelings in your legs?
(Required)
1
2
3
4
5
How often have you snored loudly, gasped, choked, or stopped breathing during sleep?
(Required)
1
2
3
4
5
How often have you used sleeping aids (i.e. tobacco, alcohol, over-the-counter medications, or prescription medications) to help you fall asleep?
(Required)
1
2
3
4
5
Do you have a job that requires night shifts?
(Required)
1
2
3
4
5
Do you have a medical condition or chronic pain that interferes with your sleep?
(Required)
1
2
3
4
5
On an average weekday do you get at least 7-8 hours of sleep in a 24-hour period?
(Required)
1
2
3
4
5
On an average weekend do you get at least 7-8 hours of sleep in a 24-hour period?
(Required)
1
2
3
4
5
Eating Patterns
Please answer based on your typical eating habits
On average, how many cups (8 oz.) of caffeinated beverages do you drink per day (tea, soda, coffee, or energy drinks)?
(Required)
0
1
2
3
4+
On average, how many servings of alcohol do you drink per day?
(Required)
0
1
2
3
4+
On average, how many cups (8 oz.) of sugary drinks (soda, sports drinks, juice) do you drink per day?
(Required)
0
1
2
3
4+
On average, how often do you snack on convenience or “junk” food per day? (i.e. chips, candy, granola bars, crackers, cookies, etc.)
(Required)
0
1
2
3
4+
On average, how many meals do you buy from a restaurant or fast food per week?
(Required)
0
1
2
3
4+
On average, do you drink at least 8 glasses of water per day?
(Required)
Yes
No
On average, do you eat at least 5 handfuls of nuts per week?
(Required)
Yes
No
Do you use natural or artificial sweeteners? (i.e. Equal, Stevia, Splenda, Sweet & Low, honey, agave, etc.)
(Required)
Yes
No
Do you add salt to most of your meals?
(Required)
Yes
No
Do you eat processed meats (i.e. sausage, hot dogs, salami, bacon)?
(Required)
Yes
No
Do you have any bad reactions (sensitivities or allergies) to food? If yes, please list here:
Do you avoid any particular foods? If yes, please list here:
Do you have foods that you crave? If yes, please list here:
Are you currently following a particular diet or nutrition plan? If yes, please list here:
During the last 3 months, did you have any episodes of excessive overeating? If yes please explain here:
Are you concerned about making the wrong food choices? If yes, please explain here:
Have you ever had an eating disorder? If yes, please list here:
Do you use any of the following VITAMINS or SUPPLEMENTS? Check all that apply.
Vitamin D
Calcium
Vitamin B12
Probiotics
Omega 3
Multivitamin
Other
Please Specify
Do you use any of the following OILS with your meals or cooking? Check all that apply.
Olive Oil
Canola Oil
Vegetable Oil
Coconut Oil
Butter
Lard
Other
Please Specify
Food Recall
Please record below what AND how much you ate and drank yesterday (or the last typical day)
Breakfast
Time
Lunch
Time
Dinner
Time
Snacks
Time
Drinks/Beverages
Time
Behavior Patterns
1=Never 2=Seldom 3=Sometimes 4=Often 5=Always
How often do you skip meals?
(Required)
1
2
3
4
5
How often do you snack in between meals?
(Required)
1
2
3
4
5
How often do you eat while watching TV?
(Required)
1
2
3
4
5
How often do you eat while in bed?
(Required)
1
2
3
4
5
How often do you have difficulty sleeping?
(Required)
1
2
3
4
5
How often do you lack physical activity or exercise?
(Required)
1
2
3
4
5
How often do you feel a lack of purpose or meaning in your life?
(Required)
1
2
3
4
5
Which of the following factors apply to your eating habits and current lifestyle? Check all that apply.
Like healthy food
Don’t like healthy food
Know how to cook healthy foods
Fast eater
Eat slowly
Read nutrition labels
Rely on packaged or fast foods
Dislike cooking
Prepare meals at home
Do not plan meals
Eat a variety of foods
Always hungry
Late night eater
Negative relationship to food
Erratic eater
No time to prepare healthy food choices
Don’t know how to cook
Live alone or eat alone often
Do any of the following situations or emotions cause you to eat? Check all that apply.
Sadness
Pain
Insomnia
Anxiety
Fatigue
Social or Family Situations
Boredom
Stress
Weight History
Have you ever been overweight or obese?
(Required)
Yes
No
Were you overweight as a child?
Yes
No
Were you overweight as a teenager?
Yes
No
Were you overweight between the ages of 20-29?
Yes
No
Were you overweight between the ages of 30-39?
Yes
No
Were you overweight above the age of 40?
Yes
No
Are you currently trying to lose or gain weight?
(Required)
Yes
No
What is your goal?
Lose weight
Gain weight
Have you ever intentionally lost or reduced your weight by more than 5 lbs.?
(Required)
Yes
No
Did you regain weight within 1 year?
Yes
No
Have you had weight loss surgery?
(Required)
Yes
No
Please list the type of surgery you had
Have you ever used weight loss medications?
(Required)
Yes
No
Which ones you have used?
Acutrim
Alli
Amphetamines
Anorex
Belviq
Byetta
Contrave
Dexatrim
Didrex
Fastin
Fenfluramine
Mazanor
Meridia
Obalan
Phendiet
Fen-Phen
Phentermine
Plegine
Prozac
Pondimin
Qsymia
Redux
Sanorex
Tenuate
Tepanol
Vyvanse
Wechless
Wellbutrin
Xenical
I don't remember the name of the medication
Other
Please Specify
Weight Loss Strategies
Have you tried any of the following alternative therapies or programs? Check all that apply.
Acupuncture
Acupressure
Nutritionist/Registered Dietitian
Residential Programs
Hypnosis
Physical Activity/Exercises
Other
Please Specify
Which commercial or fad diets have you tried in the past? Check all that apply.
Atkins Diet
Low Fat
Calorie Counting
Paleo
CHIP
South Beach
DASH
Vegan
Mediterranean Diet
Elimination Diet (Allergy)
Gluten Free
Vegetarian
Jenny Craig
Weight Watchers
Low Carb
Slim Fast/Meal Replacement
Other
Please Specify
Exercise Habits: Aerobic/Cardio Training
During the average week, how many days do you exercise at a moderate to strenuous intensity (i.e. brisk walking or enough to break a light sweat)?
(Required)
Numerical values only
During an average session, how many minutes do you exercise at a moderate to strenuous intensity (i.e. brisk walking or enough movement to break a light sweat)?
(Required)
Numerical values only
This field is hidden when viewing the form
Total min/week (days x min)
List types of aerobic activities you do (i.e. walking, jogging, swimming, bicycling, dancing, etc.)
(Required)
During the average week, how many days do you do strength/resistance training?
(Required)
Numerical values only
How many minutes do you exercise with strength/resistance training?
(Required)
Numerical values only
This field is hidden when viewing the form
Total min/week (days x min)
List types of activities you do (i.e. weightlifting, Pilates, kettle ball, resistance machines, exercise bands, etc.)
(Required)
What MOTIVATES you or would motivate you to exercise? Check top three
(Required)
Nothing would motivate me
Family or partner
Improve mood
Weight reduction
Control Blood glucose
Body Image
Increase Energy
Reduce blood pressure
Decrease stress
Prevent heart disease
Prevent Bone loss
Improve sleep
Increase self-esteem
Other
Please Specify
Are there any BARRIERS or PROBLEMS that limit exercise? Check all that apply.
(Required)
No barriers
Depression
Work Responsibility
Cost
Life Transition Period
Time
Fear
Other
Family Responsibility
Apparel
Energy
Exercise Safety
Do you have any injuries that would make it difficult to exercise?
(Required)
Yes
No
Please explain
Do you have any joint, muscle, or bone problems that might get worse with exercise?
(Required)
Yes
No
Please explain
Do you have any breathing problems while exercising?
(Required)
Yes
No
Please explain
Do you have any balance problems or have had a fall in the last 6 months?
(Required)
Yes
No
Please explain
Do you have any difficulty completing your activities of daily living (i.e. showering, dressing, toileting)?
(Required)
Yes
No
Please explain
Do you have any of the following health problems? Check all that apply.
Arrhythmia or irregular heartbeat
Uncontrolled diabetes
Recent heart attack
Arthritis or significant joint pain
Severe or uncontrolled heart failure
Chronic or unusual fatigue/tiredness
Chest pain/angina
Uncontrolled asthma
Difficulty breathing with activity
Other
Perceived Stress
1=Never 2=Seldom 3=Sometimes 4=Often 5=Always
How often have you felt that you were unable to control the important things in your life?
(Required)
1
2
3
4
5
How often have you felt lack of confidence about your ability to handle your personal problems?
(Required)
1
2
3
4
5
How often have you felt that things were not going your way?
(Required)
1
2
3
4
5
Have often have you found it hard to let go of things that upset you?
(Required)
1
2
3
4
5
How do you COPE with stress? Check all that apply.
Meditation
Food (too much, too little)
Gambling
Distraction
Exercise/Physical Activity
Spirituality/Faith
Journaling
Hurting yourself (i.e. cutting, etc.)
Counseling/Psychotherapy
Sex
Massage/Body work
Pet therapy
Socializing with friends or family
Recreational drugs (i.e. marijuana, cocaine, etc.)
Prayer
Other
Art
Television and/or video games
Substance (tobacco, alcohol)
Resilience
When I am under extreme stress
I find a way to learn from my experience.
(Required)
1
2
3
4
5
I find a way to take action.
(Required)
1
2
3
4
5
I find it easy to prioritize what is important in my life.
(Required)
1
2
3
4
5
I look at a stressful situation as an opportunity to grow.
(Required)
1
2
3
4
5
I meet the goals I set for myself.
(Required)
1
2
3
4
5
I believe that there are a lot of ways around a problem.
(Required)
1
2
3
4
5
I feel motivated to pursue my goals.
(Required)
1
2
3
4
5
I know I can get through it.
(Required)
1
2
3
4
5
Mind-Body Connection
I meet the goals I set for myself.
(Required)
1
2
3
4
5
Do thoughts or feelings affect your physical health?
(Required)
1
2
3
4
5
Could you be experiencing some emotion and not be aware of it?
(Required)
1
2
3
4
5
Are you aware of tension in your body?
(Required)
1
2
3
4
5
Do you notice how your body changes when angry?
(Required)
1
2
3
4
5
Do you notice stress in your body?
(Required)
1
2
3
4
5
Do you notice how your body reacts to emotions?
(Required)
1
2
3
4
5
Depression
Over the last 2 weeks, how often have you been bothered by the following?
Little interest or pleasure in doing things.
(Required)
0
1
2
3
Feeling down, depressed or hopeless.
(Required)
0
1
2
3
Trouble falling asleep, staying asleep, or sleeping too much.
(Required)
0
1
2
3
Feeling tired or having little energy.
(Required)
0
1
2
3
Poor appetite or overeating.
(Required)
0
1
2
3
Feeling bad about yourself or that you’re a failure or have let yourself or your family down.
(Required)
0
1
2
3
Trouble concentrating on things, such as reading the newspaper or watching television.
(Required)
0
1
2
3
Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual.
(Required)
0
1
2
3
Thoughts that you would be better off dead or of hurting yourself in some way.
(Required)
0
1
2
3
Anxiety
Over the last 2 weeks, how often have you been bothered by the following?
Feeling nervous, anxious, or on edge.
(Required)
0
1
2
3
Not being able to stop or control worrying.
(Required)
0
1
2
3
Worrying too much about different things.
(Required)
0
1
2
3
Trouble relaxing.
(Required)
0
1
2
3
Being so restless that it’s hard to sit still.
(Required)
0
1
2
3
Becoming easily annoyed or irritable.
(Required)
0
1
2
3
Purpose and Connection
How often do you agree with the following:
I live a purposeful and meaningful life
(Required)
1
2
3
4
5
I have a spiritual community that I can turn to in times of need
(Required)
1
2
3
4
5
I have a source of inner strength and meaning
(Required)
1
2
3
4
5
I am satisfied with my current belief system
(Required)
1
2
3
4
5
I have people who care about what happens to me
(Required)
1
2
3
4
5
I have people who accept me at my worst and best
(Required)
1
2
3
4
5
I have people I trust at home or work who I can talk to about my problems
(Required)
1
2
3
4
5
I get help when I’m sick
(Required)
1
2
3
4
5
Smoking and Substance History
NICOTINE/TOBACCO (i.e. cigarettes, e-cigarettes, e-cigarettes/vaping, cigars, chew, snuff)
Do you use any of the nicotine products listed above?
(Required)
Yes
No
Do you want to quit using the nicotine/tobacco products?
Yes
No
How soon after you wake up do you use nicotine/tobacco?
After 60 minutes
31-60 minutes
6-30 minutes
Within 5 minutes
How many cigarettes do you smoke per day?
10 or less
11-20
21-30
31+
What age did you start smoking?
What is the longest time period you have stayed quit?
What made you start smoking again?
Which of the following people smoke around you? Check all that apply.
Friends
Family
Partner
Co-Workers
Others
Please Specify
How many times have you seriously tried to quit?
For your most recent quit attempt, how long did it last?
Who is supporting you to quit smoking?
What is your most important reason to quit smoking?
Are you currently using or have used any medications to help you quit smoking?
Yes
No
Check with of the following medications you have used:
Nicotine Patch
Nicotine Gum
Nicotine Lozenge
Wellbutrin/Bupropion Pill
Chantix/ Varenicline Pill
Other
Please Specify
If you used any of the medication listed above, did they help?
Yes
No
List which ones helped:
Have you used any methods in the past other than medications to try to quit?
Yes
No
Which of the following methods you have used
Self-help
Gradual reduction
Cold turkey
Hypnosis
Acupuncture
Special filters
Vaping/e-cigarettes
Other
Please Specify
Alcohol
Do you drink alcohol?
(Required)
Yes
No
What type of alcohol do you prefer?
On average, how many servings do you drink per day/week/month/year on average?
Have you ever felt you should “Cut down” on your drinking?
Yes
No
Have people Annoyed you by criticizing your drinking?
Yes
No
Have you ever felt Guilty about your drinking?
Yes
No
Have you ever had a drink in the morning to steady your nerves or to get rid of a handover (eye opener)?
Yes
No
Do you binge drink (more than 5 drinks for men or 4 drinks for women within 2 hours)?
Yes
No
Have you used any of the following substances in the past year?
Recreational drugs (cocaine, heroin, meth, etc.)
(Required)
Yes
No
What level of concern do you have regarding use of the substances
0
1
2
3
4
5
How much substance do you usually use?
Marijuana
(Required)
Yes
No
What level of concern do you have regarding use of the substances
0
1
2
3
4
5
How much substance do you usually use?
Treatment History
Have you ever received treatment for a mental health problem?
(Required)
No
Yes
Have you ever received treatment for drug or alcohol use?
(Required)
No
Yes
Medical Symptom Questionairre (MSQ)
This questionnaire identifies symptoms that help to identify the underlying causes of illness, and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the PAST 30 DAYS. If you are taking after the first time, record your symptoms for the LAST 48 HOURS ONLY.
Point Scale
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Digestive
Diarrhea
(Required)
0
1
2
3
4
Constipation
(Required)
0
1
2
3
4
Bloated feeling
(Required)
0
1
2
3
4
Belching, passing gas
(Required)
0
1
2
3
4
Heartburn
(Required)
0
1
2
3
4
Intestinal/stomach pain
(Required)
0
1
2
3
4
Nausea or vomiting
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Digestive Total
Ears
Itchy ears
(Required)
0
1
2
3
4
Earaches, ear infections
(Required)
0
1
2
3
4
Drainage from ear
(Required)
0
1
2
3
4
Ringing in ears, hearing loss
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Ears Total
Head
Headaches
(Required)
0
1
2
3
4
Faintness or lightheadedness
(Required)
0
1
2
3
4
Dizziness
(Required)
0
1
2
3
4
Insomnia
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Head Total
Heart
Irregular or skipped heartbeat
(Required)
0
1
2
3
4
Chest pain
(Required)
0
1
2
3
4
Rapid or pounding heartbeat
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Heart Total
Joints/Muscles
Pains or aches in joints
(Required)
0
1
2
3
4
Arthritis
(Required)
0
1
2
3
4
Stiffness or limitations of movement
(Required)
0
1
2
3
4
Pain or aches in muscles
(Required)
0
1
2
3
4
Feeling of weakness or tiredness
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Joints Total
Lungs
Chest congestion
(Required)
0
1
2
3
4
Asthma, bronchitis
(Required)
0
1
2
3
4
Shortness of breath
(Required)
0
1
2
3
4
Difficulty breathing
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Lungs Total
Mind
Poor memory
(Required)
0
1
2
3
4
Confusion, poor comprehension
(Required)
0
1
2
3
4
Poor concentration
(Required)
0
1
2
3
4
Poor physical coordination
(Required)
0
1
2
3
4
Difficulty making decisions
(Required)
0
1
2
3
4
Stuttering or stammering
(Required)
0
1
2
3
4
Learning disabilities
(Required)
0
1
2
3
4
Slurred speech
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Mind Total
Emotions
Mood swings
(Required)
0
1
2
3
4
Anxiety, fear, nervousness
(Required)
0
1
2
3
4
Anger, irritability, aggressiveness
(Required)
0
1
2
3
4
Depression
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Emotional Total
Energy/Activity
Fatigue, sluggishness
(Required)
0
1
2
3
4
Apathy, lethargy
(Required)
0
1
2
3
4
Hyperactivity
(Required)
0
1
2
3
4
Restlessness
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Energy Total
Eyes
Watery or itchy eyes
(Required)
0
1
2
3
4
Swollen, reddened or sticky eyelids
(Required)
0
1
2
3
4
Bags or dark circles under eyes
(Required)
0
1
2
3
4
Blurred or tunnel vision (does not include near or far sightedness)
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Eyes Total
Nose
Stuffy nose
(Required)
0
1
2
3
4
Sinus problems
(Required)
0
1
2
3
4
Sneezing attacks
(Required)
0
1
2
3
4
Excessive mucous formation
(Required)
0
1
2
3
4
Hay fever
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Nose Total
Skin
Acne
(Required)
0
1
2
3
4
Hives, rashes, dry skin
(Required)
0
1
2
3
4
Hair loss
(Required)
0
1
2
3
4
Flushing or hot flashes
(Required)
0
1
2
3
4
Excessive sweating
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Skin Total
Weight
Binge eating/drinking
(Required)
0
1
2
3
4
Craving certain foods
(Required)
0
1
2
3
4
Excessive weight
(Required)
0
1
2
3
4
Water retention
(Required)
0
1
2
3
4
Underweight
(Required)
0
1
2
3
4
Compulsive eating
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Weight Total
Other
Frequent illness
(Required)
0
1
2
3
4
Frequent or urgent urination
(Required)
0
1
2
3
4
Genital itch or discharge
(Required)
0
1
2
3
4
This field is hidden when viewing the form
Other Total
Total Points
10; Mild Symptoms: 10-50; Moderate Symptoms: 50-100; Severe Symptoms: over 100
Preventive Services
Have you had a physical exam and/or “Wellness” Visit in the past 12 months?
(Required)
Yes
No
I don't know
List date and outcome
Have you had a dental exam and teeth cleaning in the past 12 months?
(Required)
Yes
No
I don't know
List date and outcome
Have you been screened for diabetes with blood work?
(Required)
Yes
No
I don't know
List date and outcome
Have you had your cholesterol, lipids or triglycerides measured?
(Required)
Yes
No
I don't know
List date and outcome
Have you ever had a bone density test to check for osteoporosis?
(Required)
Yes
No
I don't know
List date and outcome
Do you have any balance problems or have had a fall in the last 6 months?
(Required)
Yes
No
I don't know
List date and outcome
Do you have any difficulty completing your activities of daily living (i.e. showering, dressing, toileting)?
(Required)
Yes
No
I don't know
List date and outcome
Do you have any concerns about your ability to drive safely or have you had any car accidents in the past 12 months?
(Required)
Yes
No
I don't know
List date and outcome
Do you have any concerns about your memory?
(Required)
Yes
No
I don't know
List date and outcome
Do you have any trouble with your hearing?
(Required)
Yes
No
I don't know
List date and outcome
Have you had your eyes checked for vision problems?
(Required)
Yes
No
I don't know
List date and outcome
Have you ever had your metabolism or thyroid checked?
(Required)
Yes
No
I don't know
List date and outcome
Have you ever been told that you have a sexually transmitted disease/infection?
(Required)
Yes
No
I don't know
List date and outcome
If you smoke, have you ever had an abdominal ultrasound to check for possible aneurysms?
(Required)
Yes
No
I don't know
List date and outcome
Have you ever received counseling behavioral therapy for any of the following problems?
Weight management or obesity
Nutrition
Smoking or use of other nicotine products
Alcohol use
Which of the following screenings have you completed
Colon cancer screen (stool test or colonoscopy
Breast cancer screen (mammogram)
Cervical cancer screen (PAP smear)
HIV/AIDS blood work screen
Hepatitis C blood work screen
Depression or sadness screen
Have you had the following vaccines?
Flu
Hepatitis B
Pneumococcal or Pneumonia
