| Name: _________________________________________ | Physician practice or group name: ____________________________ |
| Visit date: ___________________________________________ | Visit type (circle one): Follow-up | New | Other: |
| Sex (circle one): Male | Female | Date of birth: _____________________________ |
| Event | Happened in the past year |
| Called your primary care physician office | |
| Called a specialist office | |
| Car accident | |
| Death of spouse | |
| Death of other close relative | |
| Death of a friend | |
| Death of a pet | |
| Emergency room visit | |
| Fall | |
| Hospital stay | |
| Moved | |
| New device (cane, walker, wheelchair) | |
| New non-prescription medication | |
| New prescription medication | |
| Outpatient rehab | |
| Primary care physician visit | |
| Rehab stay | |
| Specialist visit | |
| Stopped a medication on your own | |
| Stopped driving | |
| Surgery – elective | |
| Surgery – emergency | |
| Test done (blood, x-ray, other) | |
| Urgent care visit |
| Issue | Not a problem | Somewhat a problem, but tolerable | Significant problem, but tolerable | Intolerable |
| Anxiety or stress | ||||
| Caring for someone else | ||||
| Chest pain or pressure | ||||
| Constipation | ||||
| Difficulty walking | ||||
| Dizziness | ||||
| Fear of falling | ||||
| Indigestion or nausea | ||||
| Loneliness or boredom | ||||
| Low energy | ||||
| Low mood | ||||
| Managing your health problems | ||||
| Managing your medications | ||||
| Memory loss | ||||
| Needing help from others | ||||
| Overall health or quality of life | ||||
| Pain | ||||
| Poor appetite | ||||
| Poor sleep | ||||
| Sex life | ||||
| Shortness of breath | ||||
| Unsteadiness | ||||
| Urine leakage or incontinence | ||||
| Weight loss |
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