Patient Demographics

Form 1

Enter the Patient’s initials

What is your Gender?

Do you have

Female Reproductive Organs

Male Reproductive Organs

Have you ever taken hormone therapy? If so, please list the name, dose, and length of time you used the hormone.

What Is your Race/Ethnicity
?

Does the patient speak English?

Yes

type in language and translator info here:

Is the patient a _______ historian?

Fair

Good

Poor

Is the information provided by source (patient/family member) reliable?

Yes

Submit

Paitent History Continued

Social History

Patient’s Occupation

Current Living Situation

Name of living facility

Diet

Fill in specific diet

Exercise

Does the patient have any issues with ADLs?

Yes

Does the patient have any issues with ADLs?

Does the patient smoke tobacco?

Yes

Does anyone in the house smoke?

Yes

Yes, How much?

Advise cessation prompt SMOKING IS BADDDD

Does the patient drink alcohol?

Yes

How much? **Fill in if > 2 drinks/day = female, > 3 drinks/day = male**

Untitled

CAGE Score

You Might Have a Drinking Problem... Just kidding! You certianly do! Congrats! Party it up! Just kidding don\'t! You have a problem

Have you ever felt you needed to cut down on your drinking?

Yes

Have people annoyed you by criticizing your drinking?

Yes

Have you ever felt guilty about drinking?

Yes

Have you ever felt you needed a drink first thing in the morning to steady your nerves or to get rid of a hangover?

Yes

Illicit Drug Use?

Yes

What illicit drug do they use?

Family History

Patient’s Mom

Leave blank if Unknown

Patient’s Dad

Leave blank if Unknown

Submit

If you haven’t already read our page about Financial Freedom. Are you wanting to improve your financial situation? Not sure where to start? Well you’ve come to the right place!

1. Have You Pulled Your Credit Report Within The Last Two Months?

If the answer is no, then we recommend pulling your credit report. Most credit card companies now offer a monthly credit report for free. You can also use Websites like Creditkarma.com to get your free credit report. Don’t worry pulling your credit report won’t hurt your credit score. Start off by reviewing your debt accounts on your credit report to make sure they’re accurate. If there are any incorrect items on your credit report you can dispute these with through the 3 credit reporting companies.

2. Do You Have Any Financial Goals?

On your path to becoming financial independent it’s important to have your financial goals listed out. When setting financial goals make sure they are reasonable and obtainable. Setting unrealistic goals will most likely demotivate you. Start off by listing your long financial goals first. Make sure when creating goals you are specific as possible. After creating your long-term goal, create smaller/shorter-term goals to obtain your long-term goal.

Financial Goal Setting Example:

Long-term Goal:
- Retire At The Age of 55 With a Net-worth of $2.5 Million in Today’s Dollars.
Short-term Goals:
- Annually contribute $18,500 towards 401k and $5,500 for Roth IRA.
- Create and follow a budget that’s allows me to meet my annual contribution goal.

Do You Have A Budget and/or Debt Reduction Plan?

If you’re wanting to achieve financial freedom, having a budget and debt reduction plan(if you’re in debt) is a must. Planning is a big part of becoming financial independent.

Have You Started Planning & Saving For Retirement?

Knowing what you plan to spend in retirement, retirement age, and taxes are just some of the factors that go into planning for retirement. It’s never to early or late to start planning for retirement.