Pre-Consultation Health Assessment

Please complete before your VIP consultation with Dr. Tenney

Patient Information

Full Name

Date of Birth

Phone Number

Emergency Contact

Emergency Phone

Part A - Your Health Information

Please be as detailed as possible to help us serve you better

Current Chronic Conditions (check all that apply)

Diabetes

Neuropathy (nerve damage)

Arthritis

Cancer

Heart Disease

High Blood Pressure

Other (specify below)

Current Medications

List all medications including dosage and frequency

Allergies

Medication allergies, food allergies, or other relevant allergies

Current Symptoms & Severity

Rate severity: None, Mild, Moderate, Severe

Pain (location and severity)

Numbness or tingling

Fatigue or weakness

Sleep difficulties

Mobility or balance issues

Appetite or weight changes

Daily Functioning & Activities

Independent / Needs Help / Unable to Perform

Walking without assistance

Dressing yourself

Bathing/showering

Eating and drinking

Household tasks (cooking, cleaning)

Overall Pain Level (0-10)

0 = No pain, 10 = Worst possible pain

Recent Hospitalizations or ER Visits

In the past 6 months

What are your main health concerns today?

Part B - Clinical Assessment

For healthcare provider use only

Vital Signs

Blood Pressure

Heart Rate

Temperature

Weight

Clinical Observations

Physical exam findings, appearance, mental status

Assessment & Diagnosis

Recommended Actions & Treatment Plan

Follow-up Appointment Date

This questionnaire is designed to help healthcare providers better understand and manage chronic conditions in senior patients.

Date Completed: 8/27/2026

Pre-Consultation Health Assessment

Senior Health Questionnaire

Patient Information

Part A - Your Health Information

Part B - Clinical Assessment