Midland County, MI · Midland County
Annual Exam - Established Patient
Established patients complete this Family Planning Clinic form to provide health, contraception, pregnancy, and social history information for an annual exam.
At a glance
- Issued by
- City of Midland County · Midland County, Midland County, Michigan
- Notarization
- Not required: file this form without a notary.
- Official source
- midlandcountymi.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This Family Planning Clinic questionnaire collects information for an established patient's annual exam, including medical changes, medications, menstrual and contraception history, pregnancy history, and social and emotional health. It asks about relationships, safety, travel, and other health concerns. The document does not state when the clinic requires it or provide separate submission instructions.
Who needs it
Established patients completing an annual exam with the Midland County Department of Public Health Family Planning Clinic can use this questionnaire.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This clinic questionnaire is signed and dated without a notary; it includes no sworn or notarized attachment, so the patient just signs and dates it.
How to submit this form
- 1
Download the Form
Download the Annual Exam - Established Patient questionnaire.
- 2
Complete the Questionnaire
Provide the requested health, contraception, pregnancy, social, and emotional history information.
- 3
Sign and Date
Sign and date the form; it does not include a notary block.
- 4
Submit to the County
Submit it to the county department named on the form; check the county website for current contact details.
Frequently asked questions
- What information does the Annual Exam - Established Patient form ask for?
- It asks about medical changes, medications, menstrual and contraception history, pregnancy history, relationships, safety, travel, and social and emotional health.
- Who uses this Family Planning Clinic form?
- The form is for established patients completing an annual exam with the Midland County Department of Public Health Family Planning Clinic.
- Do I need a notary for the Annual Exam - Established Patient form?
- No. The document has no notary block or notarized attachment; the patient signs and dates the form.
- How do I submit the Annual Exam - Established Patient form?
- Submit it to the county department named on the form; check the county website for current contact details.