Symptoms & New Patient Form

Symptom and New Patient



Childhood Vaccinces Current
COVID-19 Series
COVID Booster
Ever tested positive for COVID?
Flu vaccine this season
Pneumonia vaccine in the last 5 years
When was your last Tetanuns Vaccination?

Patient Health Questionnaire-9 (PHQ-9)

Have you fallen in the last 30 days?
Have you traveled outside of the United States in the last 3 months?
Do you have an Advanced Directive or any other document stating your medical wishes if you could not verbalize them?
Have you ever been an employee for the Department of Energy (DOE) or Idaho National Lab (INL)?
Please circle any symptoms of illness you are currently having today or recently.
Please list any symptoms you are currently having that are not listed above


Over the last 2 weeks, how often have you been bothered by any of the following problems? (select to indicate your answer)

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
1. Little interest or pleasure in doing things