Screening · About 6 minutes

Annual wellness assessment

Complete this before your yearly visit so your clinician can review your history in advance.

About you

Full name*

Date of birth*

Telephone

Please give at least a telephone number or an email address so the office can reach you.

Current health

Ongoing medical conditions

Past surgeries or hospitalizations, with approximate years

Family history of heart disease, diabetes, cancer, or mental illness

Other clinicians or specialists you see

Lifestyle

How many days per week do you do at least 30 minutes of physical activity?*

How would you describe your usual diet?*

Balanced most daysMixedMostly convenience or fast food

Tobacco or nicotine use*

NeverFormerCurrent

Typical alcohol use per week

Preventive care

Approximate date of your last physical exam

Immunizations you believe are up to date

Preventive screenings already completed elsewhere, with dates if known

Health goals you would like to discuss this year

Submitting sends your answers directly to K. Johns Medical over an encrypted connection and creates a PDF for your clinician. It does not book an appointment and is not monitored in real time. For an urgent concern, call the office. In an emergency, call 911 or call or text 988.

Annual wellness assessment

Other screenings