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  • About
    • Our Team
    • Testimonials
    • Raleigh Patient Centered Medical Home
  • Services
    • General Medical Care
    • Abdomen Pain
    • Chiropractor Services
    • Arthritis Treatment
    • Headaches
    • Heart Disease
    • Raleigh Lower Back Pain
    • Mid-Back Pain
    • Neck and Upper Back Pain
    • Shoulder Pain
    • Sinusitis
    • Tendonitis
  • Red Light & Infrared Therapy
    • Infrared Therapy
    • Red Light Therapy
  • Laser Therapy
  • Patient Forms
    • New Patient Packet
    • Medical Record Request
    • Medical Record Release
    • Wellness Visit
  • The Sticky Note Diet
  • Pay Your Bill
  • Request an Appointment

919-850-1300

Our Location

Wellness Visit

Wellness Visit

MM slash DD slash YYYY
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. 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 pay
Patient Name(Required)
MM slash DD slash YYYY

Please check all that apply to you:

Please check all that apply to you:
ALLERGIES:
CARDIOVASCULAR:
GENERAL/CONSTITUTIONAL SYMPTOMS:
EARS, NOSE, MOUTH, and THROAT:
ENDOCRINE:
EYES:
GASTROINTESTINAL:
GENITOURINARY:
MM slash DD slash YYYY
MM slash DD slash YYYY
HEMATOLOOGIC/LYMPHATIC:
PSYCHIATRIC:
INTEGUMENTARY (SKIN):
MUSCULOSKELETAL:
NEUROLOGICAL:
RESPIRATORY:

Established Patients:

Please only indicate if anything has changed
PERSONAL MEDICAL HISTORY (Check all that apply)
DISEASE/CONDITION
Current
Past
Comments
 
Dose MEDICATIONS (Include over the counter)
MEDICATIONS
Dose
Times Per Day
 
ALLERGIES (Include food/environmental allergies)
ALLERGY
Reaction
 
SERIOUS INJURY/SURGERIES/HOSPITALIZATIONS (Include childbirth)
TYPE
Date
Facility
 
SPECIALISTS (Eye Doctor, Cardiology, Gastroenterology, Ob/Gyn, etc)
SPECIALIST
Name
Last Visit/Frequency of Visits
 

HEALTH MAINTENANCE/VACCINATIONS

Last Physical Exam/Wellness
Date:
Facility:
Abnormal Result?
 
Cholesterol Screen
Date:
Facility:
Abnormal Result?
 
Colonoscopy
Date:
Facility:
Abnormal Result?
 
Mammogram
Date:
Facility:
Abnormal Result?
 
Pap Smear
Date:
Facility:
Abnormal Result?
 
Bone Density
Date:
Facility:
Abnormal Result?
 
Last Tetanus Booster
Date:
COVID Vaccine (s)
Date (s):
 
Last Flu Vaccine
Date:
Pneumonia Vaccine (s)
Date (s):
 
Zoster Vaccine(Shingles)
Date:
HPV Vaccine (s)
Date (s):
 

FAMILY MEDICAL HISTORY

MGM= maternal grandmother, MGF= maternal grandfather, PGM= paternal grandmother, PGF= paternal grandfather
Deceased? At what age?
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Alcoholism/ Drug Abuse
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Asthma
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Cancer (specify)
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Depression / Anxiety / Bipolar
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Type 2 Diabetes
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Emphysema (COPD)
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Heart Disease
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Hypertension
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
High Cholesterol
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Thyroid Disease
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Kidney Disease
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Migraine Headaches
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Stroke
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
Other
Mother
Father
Brother/s
Sister/s
MGM
MGF
PGM
PGF
 

PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling down, depressed, or hopeless
Little interest or pleasure in doing things
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself —or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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
Thoughts that you would be better off dead or of hurting yourself in some way
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

SOCIAL HISTORY

2. Have you ever smoked tobacco?
a. Current smokers:
b. Past smokers
5. Do you drink alcohol?
9. Check if your work exposes you to the following:
  • Wellness Visit

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