Patient date of birth*

Do you have any concerns you’d like to discuss today?*

Have any of your relatives developed new medical problems since your last physical?*

Do you have any concerns about your eating, nutrition, or weight?*

Do you have any concerns about your sleep, including trouble falling or staying asleep, snoring, or daytime sleepiness?*

Any urinary concerns?*

Any stomach or bowel movement concerns?*

Are you currently in school, working, or both?*

Do you have any concerns about school, work, or your plans for the future?*

Do you feel safe at home, at school/work, and in your relationships?*

Does you get at least 1 hour or more of physical activity daily?*

Anemia risk: Do you have limited access to food, eat a diet low in iron-rich foods (such as meat, iron-fortified cereals, or beans), or have heavy/prolonged periods?*

TB risk: Have you had close contact with someone with tuberculosis, lived in or traveled to a country where TB is common, or do you have HIV?*