Healthsprings 360 Wellness Form Name(Required) First Last Phone(Required)Email DOB(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Marital Status(Required)SingleMarriedDomestic PartnerDivorcedWidowedLives(Required)AloneSpouseInstitutionalFamilyOtherExplain "other"(Required) Pain Level(Required)12345678910Is bladder control a problem?(Required)NoYesHow many days a week are you physically active?(Required)0-1 days2-3 days4 or more daysFamily HistoryHypertension(Required) Father Mother Children Siblings Grandparents None of these Heart Disease(Required) Father Mother Children Siblings Grandparents None of these Stroke(Required) Father Mother Children Siblings Grandparents None of these Diabetes(Required) Father Mother Children Siblings Grandparents None of these High Lipids(Required) Father Mother Children Siblings Grandparents None of these Dementia(Required) Father Mother Children Siblings Grandparents None of these Depression(Required) Father Mother Children Siblings Grandparents None of these Cancer(Required) Father Mother Children Siblings Grandparents None of these Other(Required) Father Mother Children Siblings Grandparents None of these List Other(Required)Tobacco Use(Required)NoYesType of Tobacco Use(Required) E-Cigarettes Chew/Dip Current smoker Previous smoker How many packs per day?(Required)Please enter a number from 0 to 10.What year did you quit smoking?(Required) Alcohol Use(Required)NoYesHow many drinks per day?(Required)Please enter a number from 0 to 20.Is alcohol usage a concern for you or others?(Required)NoYesQuestionnaire:Have you felt depressed or down-and-out over the past 2 months?(Required)NoYesHave you had a loss of interest in things that normally bring you pleasure?(Required)NoYesHave you felt fatigued or had a loss of energy recently?(Required)NoYesPreventive Screenings(If yes, please provide date & location)Osteoporosis Screening(Required)NoYesDate(Required) Month Day Year Location(Required) Mammogram(Required)NoYesDate(Required) Month Day Year Location(Required) Colorectal Cancer Screening(Required)NoYesDate(Required) Month Day Year Location(Required) Advanced Care Plan(Required)NoYesDate(Required) Month Day Year Did you provide a copy?(Required)YesNoVaccine HistoryInfluenza Vaccine(Required)NoYesDate(Required) Month Day Year Pneumococcal Vaccine(Required)NoYesDate(Required) Month Day Year Shingles Vaccine(Required)NoYesDate(Required) Month Day Year Prevnar(Required)NoYesDate(Required) Month Day Year COVID(Required)NoYesDate(Required) Month Day Year EmailThis field is for validation purposes and should be left unchanged.
