Preventive Care Follow-Up Assessment Form
Please complete this form to help us assess your preventive care follow-up and ensure you receive the best support.
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which preventive care service did you recently receive?
*
Please Select
Annual Physical Exam
Vaccination
Screening Test
Health Counseling
Other
How would you rate your overall experience with your recent preventive care follow-up?
*
1
2
3
4
5
Since your last visit, have you experienced any new symptoms or health concerns?
*
Yes
No
If yes, please describe your new symptoms or concerns:
Please indicate how well you have been able to follow the recommendations provided during your preventive care visit.
*
Rows
Not at all
Somewhat
Mostly
Completely
Medication
1
2
3
4
Diet
5
6
7
8
Exercise
9
10
11
12
Screenings/Tests
13
14
15
16
Other Recommendations
17
18
19
20
How confident do you feel about managing your health after your preventive care visit?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Would you like additional support or resources?
*
Yes
No
Please share any additional comments or suggestions to help us improve our preventive care follow-up.
Submit Assessment
Should be Empty: