1220 Biltmore Drive • Lawrence, KS 66049
Lawrence Family Medicine & Obstetrics
Dr. Rod Barnes
Dr. Malati Harris
Dr. Larisa Kimuri
Dr. Pamela Huerter
Dr. Lori Nichols
Dr. Steven Bruner
Dermatology and Dermatologic Surgery
Electronic Health Record and Quality Assurance Plans
Health Information Release
Patient Info Sheet
Privacy Practice Information
Privacy Notice Form
Well Child Checks
2 Month ASQ
4 Month ASQ
6 Month ASQ
9 Month ASQ
12 Month ASQ
16 Month ASQ
18 Month ASQ
24 Month ASQ
36 Month ASQ
48 Month ASQ
54 Month ASQ
60 Month ASQ
KAN Be Healthy (EPSDT) Screening Form
Have you had any serious or chronic illnesses?:
If yes, describe and age it began:
Have you had any surgeries?:
If yes, describe and date of surgery:
Have you been hospitalized for any reason other than surgery?:
Are you taking any medications, including over the counter or herbal, on an onging basis?:
If yes, please list them:
Condition begin treated/Symptoms
Have you had any allergies or adverse reactions to medication?:
If yes, please list the medication and the type of reaction:
Type of Reaction
Do you have a family history (mother, father, brothers or sisters) of cancer, heart disease, diabetes or other serious illnesses?:
Age of Onset
Do you use any of the following tobacco products?
If yes, how much?
Have you used tobacco products in the past?
If yes, how many years did you use tobacco?
Do you use alcohol?
More than 2/day
How many days per week do you exercise?
What type of exercise?
Do you wear your seatbelt?
Have you had your cholesterol checked?
When was you last tetanus shot?
If you are a female over age 21, when was your last pap smear?
If you are a female over age 40, when was your last mammogram?
If you are over age 50, when was your last colon exam?
If you are over age 65, have you been vaccinated for pneumonia?
Number of Children?
Number of Pregnancy's?
What else would you like to the doctor to know about yourself?
How did you select this office for your care?
Lawrence Family Medicine & Obstetrics © 2014