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Have you received your annual flu vaccine? YES NO Month: ________________________ Year: _____________________

If so was it: HI DOSE REGULAR I DON’T KNOW

Have you ever received a Pneumonia vaccine? YES NO Month: ________________________ Year: _____________________

If so was it: PNEUMOVAX PREVNAR 13 I DON’T KNOW

Have you ever had a mammogram? N/A YES NO Month: ________________________ Year: _____________________

If so was it: NORMAL ABNORMAL FINDINGS :___________________________________

v. 03-05-2018

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v. 03-05-2018

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