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PUHMED® Wellness Assessment Form

Please complete this form to help us understand how to provide the best care for you. Please answer the questions to the best of your knowledge by circling and sharing with the doctor.

Personal Information

Last Name:
First Name:
Date of Birth:
Patient Number:
PUHMED® Member Number:

Clinician Information

Clinician’s Last Name:
First Name:
Today’s Date:
Clinician PUHMED®/ National ID Number:
Phone Number:
Visit Number:

Assessment

How much did the following problems bother you?

Problem Not At All A Little Somewhat A Lot
Nervousness or shakiness during Diagnosis?

Agreement Statements

How Much Do You Agree with the Following

Statement Strongly Agree Agree Disagree Strongly Disagree
I felt better after my first visit.

Additional Information

What other services would you want to access from this facility? (Please Explain)
Have you Paid Any Money to this facility for this particular treatment? Yes No
If Yes, For What purposes did you pay this money?

Thank you for filling the Wellness Assessment Form. For any Complaints, please write to ALERT@realhealthuganda.org Or Call +256 41 467 1109