Complete Physical Exam for Patients of Dr. Lance Rudolph

Please enable JavaScript in your browser to complete this form.

Step 1 of 2

If you prefer to print this form, fill it out by hand, and bring it with you to your appointment, please CLICK HERE.

Layout

Name

First

Last

Do you have Medicare or a Medicare Advantage Plan?

Date of Birth

	Never	Seldom	Sometimes	Often	Always
Falling or dizzy when standing up.	NeverFalling or dizzy when standing up. Never	SeldomFalling or dizzy when standing up. Seldom	SometimesFalling or dizzy when standing up. Sometimes	OftenFalling or dizzy when standing up. Often	AlwaysFalling or dizzy when standing up. Always
Sexual problems	NeverSexual problems Never	SeldomSexual problems Seldom	SometimesSexual problems Sometimes	OftenSexual problems Often	AlwaysSexual problems Always
Trouble eating well	NeverTrouble eating well Never	SeldomTrouble eating well Seldom	SometimesTrouble eating well Sometimes	OftenTrouble eating well Often	AlwaysTrouble eating well Always
Teeth or denture problems	NeverTeeth or denture problems Never	SeldomTeeth or denture problems Seldom	SometimesTeeth or denture problems Sometimes	OftenTeeth or denture problems Often	AlwaysTeeth or denture problems Always
Problems using the telephone	NeverProblems using the telephone Never	SeldomProblems using the telephone Seldom	SometimesProblems using the telephone Sometimes	OftenProblems using the telephone Often	AlwaysProblems using the telephone Always
Tiredness or fatigue	NeverTiredness or fatigue Never	SeldomTiredness or fatigue Seldom	SometimesTiredness or fatigue Sometimes	OftenTiredness or fatigue Often	AlwaysTiredness or fatigue Always

Clinical Research

All Studies

Frequently Asked Questions

News

Events and Happenings

Newsletters

Patient Information

New Patient Forms

Physical Exam Forms

Bone Density Forms

About

Careers

Privacy Statement

No Show/Cancellation Policy

Providers

Staff

Facility

Sponsor Information

General Information

Contact

300 Oak Street NE, Albuquerque, NM 87106

Medical Practice

Phone:505-855-5525

Fax: 505-884-4006

Billing:505-855-5525

Emergency: 505-857-3844

Research Center

Phone: 505-855-5505

Fax: 505-855-5506

Emergency: 505-857-3844

Study Recruiter: 505-923-3232

Complete Physical Exam for Patients of Dr. Lance Rudolph

If you prefer to print this form, fill it out by hand, and bring it with you to your appointment, please CLICK HERE.

STOP – This form is for patients who have Medicare or a Medicare Advantage Plan for their insurance coverage. Contact our office at 505-855-5525 if you need guidance.

THE FOLLOWING QUESTIONS ARE FOR PATIENTS WITH MEDICARE OR A MEDICARE ADVANTAGE PLAN ONLY.

Depression Screening Questionnaire

Medicare Wellness Checkup

Thank you very much for completing your Medicare Wellness Checkup. Please press ‘Submit’ or print and give the completed checkup to your doctor or nurse.

Appealing Insurance Denials