ANNUAL PATIENT INFORMATION UPDATES

1 ANNUAL PATIENT I NFORMATIO N UPDATES Pat ie nt Name: DOB: Today s Dat e: Email:Pref er red Phar mac y: Pharmac y Locatio n:Pharmac y Tel ephone:For Office Use Only: Portal Invite Sent ADVANCE CARE DIRECTIVES Do you hav e a liv ing will? Yes No Do you hav e a healthcar e power of attorney? Yes No Do you hav e a DNR (Do Not Resuscit at e) or der ? Yes No If you answered Y es to any of th e abov e questions, pl ease provid e our of fice wit h a copy for your records IMMUNIZ ATIONS Hav e you received a Pneumonia Vac cine? Yes Dat e_____ No Hav e you received an Influenza Vac cine?

2 Yes Dat e_____ No SMOKING STATUS Ple as e Sele ct One: Smoker Former Smoker Nev er Smoked ROUTINE SCREENINGS Hav e you ever had a col onos copy? Yes No Date_____ Office Use:73761001 Hav e you ever had a mammogram? Yes No Date_____Office Use:24623002AO-052 Ordering Physician:_____Ordering Physician:_____Primary Care Physician:_____Surgeon:_____