Patient Self Assessment

Today’s Date ____________

Name _______________________________________________________
DOB _________________

1. When was your last physical done? ___________________________

2. What is your Body Mass Index (BMI)? _________________________
     (see reverse chart to calculate)

3. Feeling Score ___________________  (see reverse)

4. Pain Score ___________________  (see reverse)

5. Health Habit Score ___________________  (see reverse)

6. Are your pills making you ill?  (circle one)

	Yes		No 		Maybe		Not Applicable

7. Are you confident in managing your health problems?  (circle one)

	Yes		No		Maybe		Not Applicable

8. Do you have any other questions or concerns?
     (please state in the space provided)

After you complete this form, tear off the bottom as a reminder to go to www.howsyourhealth.org and enter our office code ____.  We ask our 
patients to use this website to improve their health and help us improve 
the healthcare we deliver.          	Thank You