Georgia Kidney Associates

Edward D. Himot, MD., Indira Chervu, M.D., F.A.C.P., Robert D. Jansen, M.D., Akin O. Ogundipe, M.D., F.A.C.P.,
Vijay Nath, M.D., Sandeep Jaglan, M.D., Amish Patel, M.D., Kimone James, M.D., Samuel A. Johnson, M.D.

Preventive Health Questionnaire
First Name:

Last Name:

Date:

Please indicate the last time you had the following preventive health exams and/or immunizations:

All Patients If Diabetic
Colonoscopy: Vision Screening:
Sigmoidoscopy: Podiatry (Foot) Exam:
Cholesterol Screening: Hemoglobin A1C
If Male If Female
PSA: Mammogram:
Prostate Exam: Breast Exam:
Pap Smear:
Adult Immunizations Childhood Immuinzations:   (Circle Yes or No)
Tetanus: Mumps: Yes
No
Influenza: Measels: Yes
No
Pheumonia: Rubella: Yes
No
Hepatitis A: Chicken Pox: Yes
No
Hepatitis B:

Other Physicians:

Name: Address:
Name: Address:
Name: Address:
Name: Address: