7. Spirituality 8. Physical Activity -type, frequency 9. Occupational History—exposures, current work status/responsibilities/deployment 10. Nutrition-eating history/disorders 11. Other as appropriate (finances, living situation, caffeine, safety, etc.) Health Promotion/Immunizations History (if applicable) 1. Immunizations 2. Last dental and eye exams 3. Last PE and age-appropriate screenings (e.g., osteoporosis, mammography, prostate cancer, colonoscopy, dementia) 2 1

Sexual/Reproductive History (if applicable) 1. OB/GYN Hx 2. Partners 3. Practices 4. Female: LMP 5. Sexual satisfaction/issues 1

Functional Health (if applicable) 1. Activities of daily living (ADLs) • Bathing • Dressing • Toileting • Feeding • Mobility 2. Instrumental activities of daily living (IADLs) • Traveling • Managing finances • Managing Medications • Shopping • Household chores • Sensory assessment (hearing/vision) • Gait and balance 1

Psychological Health (if applicable) Cognitive disorders (delirium, dementia, mild cognitive impairment)-Use a screening tool (e.g., Mini-Mental Exam) Affective disorders (depression)-Use a screening tool (e.g., PH-Q9) Spiritual well-being 1

Quality of Life Measures (if applicable) Environmental conditions Social conditions Physical conditions Personal resources (mental health, life perspective) 1

Review of Systems (in context of complaint) Constitutional Skin HEENT/Mouth Neck Lymph Chest/Breasts/Respiratory 5