Patient Forms

​​​​The following forms are for patients of UW Neighborhood Clinics. Please bring the completed visit or history forms with you to your appointment.  With a little planning before each visit, you and your provider will be able to focus on the issues that are most urgent and matter the most to you.

Sports Physical Forms

To be completed by the parent/guardian of the patient prior to his/her Sports Physical appointment.

Medicare Forms

Medicare - Initial Annual Wellness Visit Form (PDF) 
To be completed by patients who have been eligible for Medicare for more than 12 months.
Medicare - Subsequent Annual Wellness Visit Form (PDF) 
To be completed by patients who have had their initial exam at least 365 days ago.
Medicare - Welcome To Medicare (PDF) 
To be completed by patients who have been eligible for Medicare for less than 12 months.

New Patient

Preparing for Your Visit (PDF) 
To be filled out by all patients to help you prepare for your upcoming visit. 
Medication History Form (PDF) 
To be completed by new and established patients prior to an office visit.
New Adult Health Questionnaire (PDF)   
To be filled out by adult patients who are establishing care with a UW Neighborhood Clinics provider.

Conditions Related Forms

Anticoagulation Visit Form (PDF) 
This form should be filled out by Coumadin patients prior to each anticoagulation visit. 
Diabetes Questionnaire (PDF) 
To be filled out by patients with diabetes prior to each diabetes visit.

Other Forms

Accessing Medical Records(links to UW Medicine medical records page)

Sleep Clinic Patient Questionnaire
To be filled out by patients before their sleep clinic appointment.

Nutrition Questionnaire (PDF)
 
To be filled out by patients prior to their first visit with the Nutritionist. 

Permission to Treat a Minor Without a Parent/Guardian Present (PDF) 

Prenatal History Form (PDF) 
To be filled out by pregnant women who are establishing obstetrical care with a UW Neighborhood Clinics provider.

Preparing for Your Visit (PDF) 
To be filled out by all patients to help you prepare for your upcoming visit. 

Medication History Form (PDF) 
To be completed by new and established patients prior to an office visit.