Wellness Visit Wellness Visit Date(Required) MM slash DD slash YYYY MRN Dear Valued Patient, Annual wellness exams are an excellent way to take a proactive approach to your health care. In many cases, your insurance company may support these visits by waiving copays and laboratory charges for certain preventive services. Thank you for choosing our practice for your preventative health needs and we are happy to address any other medical concerns you may have. Please be aware that if you are seen for preventive care and your provider assesses and treats any concerns or problems during the wellness exam, it is considered a problem-focused exam. Rather than schedule a second visit for a later day, for your convenience, we may address all your concerns while you are already in the office for your wellness visit if you would like to focus only on preventive care today. we can help schedule another visit with your provider to address other concerns. If your visit is both for annual wellness concerns and problem-focused concerns, your insurance may process your visit as two separate office visits. Both the annual wellness exam and the problem-focused exam will be reflected in your explanation of the benefits statement from your insurance company. As a result, you may be subject to a copay, co-insurance, or deductible for the problem-focused portion of your visit. Each patient is responsible for verifying any payable benefits for wellness visits and coverage of other conditions with their individual insurance carrier on the date of service. Our office enters the insurance claim based on the entirety of services and tests done during your visit. MedOneMedical Group cannot guarantee coverage of your insurance claim or any specific insurance payment amounts. I have read and understand the above information. fi my insurance plan considers today’s visit two separate exams and requires additional out-of-pocket expense. I understand that it is my responsibility to payPatient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Chart Please check all that apply to you:Please check all that apply to you: No problems ALLERGIES: No problems Hives/skin rashes Runny nose Food allergies Itchy eyes Hay Fever Sneezing Mold Others CARDIOVASCULAR: Ankle swelling Chest pain Palpitations Hypertension Irregular Heartbeats Painful legs Shortness of breath Varicose veins Others Other (ALLERGIES) Other (CARDIOVASCULAR) GENERAL/CONSTITUTIONAL SYMPTOMS: Appetite change Chills Dizziness Fever Fatigue Headache Hot flashes Nausea Vomiting Sleep Problems Weight Change Others EARS, NOSE, MOUTH, and THROAT: Blisters in mouth Cough Difficulty hearing Difficulty swallowing Sore throat Hoarseness Jaw pain Nasal pain Ringing in ears Sinus problems Ear pain Others Other (GENERAL/CONSTITUTIONAL SYMPTOMS) Other (EARS, NOSE, MOUTH, and THROAT) ENDOCRINE: Cold intolerance Dry skin Flushing Hair loss Heat intolerance Diabetes Menopause Sluggish Height loss Thirst Others EYES: Blurred vision Dry eyes Eye discharge Loss of vision Eye pain Photosensitivity Visual changes Watering eyes Others Other (ENDOCRINE) Other (EYES) GASTROINTESTINAL: Abdominal pain Bloating Blood in stool Constipation Rectal Bleeding Diarrhea Gas Hemorrhoids Indigestion IBS Others GENITOURINARY: Abnormal PAP Blood in urine Overactive bladder Decreased libido Urinary problems Vaginal discharge Painful testicles Erectile dysfunction Menstrualpain Others Other (GASTROINTESTINAL) Other (GENITOURINARY) Date of last PAP MM slash DD slash YYYY Date of last period MM slash DD slash YYYY HEMATOLOOGIC/LYMPHATIC: Bleeding problems Blood clotting problems Swollen lymph nodes Bruise easily Anemia Others PSYCHIATRIC: Mood changes Anxious Suicidal thoughts Panic attacks Depression Others Other (HEMATOLOOGIC/LYMPHATIC) Other (PSYCHIATRIC) INTEGUMENTARY (SKIN): Acne Blisters Boils Change in mole Breast lump Non-healing wound Eczema Dry skin Others MUSCULOSKELETAL: Arthritis Back pain Joint pain Neck pain Leg pain Muscle pain MVA injury Sciatica Others Other (INTEGUMENTARY) Other (MUSCULOSKELETAL) NEUROLOGICAL: Migraine Confusion Vertigo Seizures Difficulty concentrating/speaking Syncope Tremors Paralysis Others RESPIRATORY: Asthma Breathing difficulty Pneumonia Coughing up sputum Dyspnea Sleep apnea Snoring Wheezing Others Other (NEUROLOGICAL) Other (RESPIRATORY) Established Patients: Please only indicate if anything has changedPERSONAL MEDICAL HISTORY (Check all that apply)DISEASE/CONDITIONCurrentPastComments Add RemoveDose MEDICATIONS (Include over the counter)MEDICATIONSDoseTimes Per Day Add RemoveALLERGIES (Include food/environmental allergies)ALLERGYReaction Add RemoveSERIOUS INJURY/SURGERIES/HOSPITALIZATIONS (Include childbirth)TYPEDateFacility Add RemoveSPECIALISTS (Eye Doctor, Cardiology, Gastroenterology, Ob/Gyn, etc)SPECIALISTNameLast Visit/Frequency of Visits Add RemoveHEALTH MAINTENANCE/VACCINATIONSLast Physical Exam/WellnessDate:Facility:Abnormal Result? Add RemoveCholesterol ScreenDate:Facility:Abnormal Result? Add RemoveColonoscopyDate:Facility:Abnormal Result? Add RemoveMammogramDate:Facility:Abnormal Result? Add RemovePap SmearDate:Facility:Abnormal Result? Add RemoveBone DensityDate:Facility:Abnormal Result? Add RemoveLast Tetanus BoosterDate:COVID Vaccine (s)Date (s): Add RemoveLast Flu VaccineDate:Pneumonia Vaccine (s)Date (s): Add RemoveZoster Vaccine(Shingles)Date:HPV Vaccine (s)Date (s): Add RemoveFAMILY MEDICAL HISTORY MGM= maternal grandmother, MGF= maternal grandfather, PGM= paternal grandmother, PGF= paternal grandfatherDeceased? At what age?MotherFatherBrother/sSister/sMGMMGFPGMPGFAlcoholism/ Drug AbuseMotherFatherBrother/sSister/sMGMMGFPGMPGFAsthmaMotherFatherBrother/sSister/sMGMMGFPGMPGFCancer (specify)MotherFatherBrother/sSister/sMGMMGFPGMPGFDepression / Anxiety / BipolarMotherFatherBrother/sSister/sMGMMGFPGMPGFType 2 DiabetesMotherFatherBrother/sSister/sMGMMGFPGMPGFEmphysema (COPD)MotherFatherBrother/sSister/sMGMMGFPGMPGFHeart DiseaseMotherFatherBrother/sSister/sMGMMGFPGMPGFHypertensionMotherFatherBrother/sSister/sMGMMGFPGMPGFHigh CholesterolMotherFatherBrother/sSister/sMGMMGFPGMPGFThyroid DiseaseMotherFatherBrother/sSister/sMGMMGFPGMPGFKidney DiseaseMotherFatherBrother/sSister/sMGMMGFPGMPGFMigraine HeadachesMotherFatherBrother/sSister/sMGMMGFPGMPGFStrokeMotherFatherBrother/sSister/sMGMMGFPGMPGFOtherMotherFatherBrother/sSister/sMGMMGFPGMPGF Add RemoveSOCIAL HISTORY1. How much exercise do you get weekly? 2. Have you ever smoked tobacco? Yes No a. Current smokers: Yes No How long have you smoked? How much currently smoking? b. Past smokers Yes No Quit date How long did you smoke? How much did you smoke? 3. Do you have any secondhand smoke exposure? 4. Do you use any drugs? (Please specify) 5. Do you drink alcohol? Yes No a. How much do you drink weekly? b. What do you typically drink? 6. What is your occupation (retired, disabled, unemployed) 7. If not USA, what is your country of origin? 8. If not English, what is your preferred language? 9. Check if your work exposes you to the following: Stress Hazardous Substances Heavy lifting Other Other. (work exposes) 10. Do you have trouble functioning in everyday tasks due to anxiety, memory loss, location or other reasons? 11. Do you have a lack of social support at home? 12. Do you feel your over all health is adversely affected by here you live or work? 13. Are you unable to afford care or prescriptions? 14. Are you unable to obtain proper nutrition? 15. Is your home/workplace unsafe?