Patient Safety Tool: Preventive Services Patient Data Collection Form

The Oklahoma Foundation for Medical Quality, the Medicare quality improvement organization for Oklahoma, provides a free, downloadable preventive services patient data collection form for use in physician offices.


The form is used to collect information from patients about when and where they received their latest preventive services.


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There is a one-page form for female patients and a one-page form for male patients.


Download the preventive services patient data collection form (pdf) developed by the Oklahoma Foundation for Medical Quality for adaptation and use in your facility.


Note: View our database providing more than 100 reports that link to free, downloadable and adaptable tools for use in surgery centers, hospitals and other organizations by clicking here.


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