MEDICARE PATIENT INTAKE FORM
PATIENT INTAKE FORMPlease answer the following questions:PATIENT NAME:___________________________________________Did you receive the flu vaccine for the 2019/20 flu season? Yes or No*If you have not received the flu vaccine we recommend that you talk to your primary doctor.*Have you ever received the pneumonia vaccine in your lifetime? Yes or No*If you are over 65 years old you should receive the pneumonia vaccine*Do you smoke? Yes or No*If you smoke we recommend stopping and can provide smoking cessation information.*MEN: How often last year did you have 5 or more drinks in a day? 0 1 2+ WOMEN: How often last year did you have 4 or more drinks in a day? 0 1 2+Who is your Primary Care Physician?: __________________________What is your current Pharmacy?_______________________________Do you give permission to release medical information to another family member, and if so please list their name(s) below:Name:_________________________ (Relationship)________________________Name:_________________________ (Relationship)________________________SIGNATURE:__________________________________________________________ ................
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