SCREENING FORMS

For clinical screening during an in-person or telehealth appointment. 

ANNUAL TAM

Please complete the annual tobacco, alcohol, and mood screening for your annual preventive / wellness exam.

Iris, Concierge Support

ADD/ADHD

Please complete the survey instrument at the direction of a medical provider.

Iris,Concierge Support

PHQ-9 & GAD-7 (combo)

For positive PHQ2 screenings or for patients with previous F diagnosis. Ask physician first.

Iris, Concierge Support

ESTABLISHED VISIT

Please complete this questionnaire before your appointment.

Iris, Concierge Support

PTSD-Civilian

Online for for people who display stress. Only given under direction of medical provider.

Iris, Concierge Support

COVID

Each patient receives a COVID screening before an in-person appt.

Kristen, Practice Manager

PRACTICE INFORMATION​

COMMUNICATION

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Clinic: 156 Sagamore Parkway W. Ste A in West Lafayette, Indiana

PARTICIPATING INSURANCE

Employee Plans LLC

Medishare

©2021 by Coze Health Medical LLC