Visit Planner (version 5.0) Return this form to front desk. Feedback provided will be incorporated into the patients registry profile.

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1 MRN: 1 Patient Name: TEST, PATIENT T DOB: 1/1/1985 3/4/ :00:00 AM Provider: MALONE 3/17/2471 Visit Barrier: Multiple No Shows Patient Needs: Interpreter Score PHQ2 Depression Assessment Over the past 2 weeks, how often have you lost enjoyment or taken little interest in your usual activities? Over the past 2 weeks, how often have you felt down, depressed, or hopeless? * Choices: 0=Not at all 1=Several days 2=More than 1/2 the days 3=Nearly every day * Add score of 2 questions and enter total. If score equals 3 or more, flip this page over and have patient fill out PHQ9. Diabetes Retinal Exam Has patient had an eye exam within past 12 months? Was PHQ9 given to patient? * If out-of-date or unknown, we recommend retinal photos today. If has had exam within past 12 months stop here.* Does patient want retinal camera visit today? If no camera today, does patient want retinal camera at next visit? If patient refuses camera, referral to UNC for dilated retinal exam? Foot History Have you had an amputation of toes, a foot or a limb? Have you had ulcers, sores or infections of your feet? (If yes, contact CA and send to Rm 3105 after visit) Have you been told that you have peripheral vascular disease or blockages in the blood flow to your feet? Have you seen a foot doctor within the last year? If so, date seen / / Do you wear diabetic shoes? Depression Screening, Review PHQ Results * If PHQ2 >=3 patient may be depressed, PHQ9 needed. * Is PHQ2 score >= 3? (see above) If yes, did you score PHQ9 and complete prompts on back? Antithrombotic Indicated * Aspirin, aggrenox, plavix or Coumadin not in CIS med list. * Score Age > 40 yrs, Aspirin Indicated * Aspirin or aggrenox not in CIS med list. *

2 MRN: 2 Patient Name: TEST, PATIENT T DOB: 1/2/1985 3/4/ :00:00 AM Provider: MALONE 3/18/2471 Visit Barrier: Multiple Late Arrivals Patient Needs: Transportation Issues Score Tobacco Use Current * Choices: 1=Recent cessation 2=Previous smoker 3=Current smoker 4=Smokeless Tobacco * Nurse advised patient to quit tobacco? Does patient want to quit tobacco in next 30 days? Care Assistant contacted for counseling? Score Foot Exam Indicated The patient felt '7 of 8' or '8 of 8' sites on their feet? Skin fissure or maceration present? Ulcer present? Foot deformity present? Callus present? Result: of Pneumovax Indicated Patient had previous pneumovax? / / at UNC or Outside Facility If no, given today? If not given today, was pneumovax refused? If not given today, was pneumovax delayed until next visit? If not given today, was it contraindicated? Patient has high risk foot, provider f/u Due Did you review the nurse foot exam? Did you make a referral to podiatry today? Did you give a Rx for diabetic shoes today? Contraceptive Assessment Indicated What is the patient s contraceptives status? A=abstinence, B=barrier, C=contraception(hormonal/IUD), H=hysterectomy, M=menopause T=tubal ligation Urine Microalbuminuria Due * ACE/ARB not in med list AND no micral in last year. * Urine micral ordered today?

3 MRN: 3 Patient Name: TEST, PATIENT T DOB: 1/3/1985 3/4/ :00:00 AM Provider: MALONE 3/19/2471 Patient Needs: Interpreter Score Dietician Visit Assessment DV Screen Indicated In the past year, has your partner hit, kicked or otherwise hurt or threatened you? Do you feel unsafe in your current relationship? Is there a partner from a previous relationship who is making you feel unsafe now? If any answer is 'Yes', contact Beacon Program. Beacon Program contacted? If any answer is 'Yes', notify provider. Provider notified? /20/2009 Contraceptive Education Indicated * Contraceptive status less than 100% effective * Educate about risk of pregnancy on ACE/ARB, statin, warfarin Status update? H=hysterectomy, M=menopause, T=tubal ligatio Statin Initiation Indicated * Not at goal of LDL<100 and/or non-hdl<130. * ACE-I or ARB Indicated * ACE/ARB not in med list AND last BP not at goal. *

4 MRN: 4 Patient Name: TEST, PATIENT T DOB: 1/4/1985 3/4/ :00:00 AM Provider: MALONE 3/20/2471 Visit Barrier: Multiple Late Arrivals Score --No prompts indicated today-- --No prompts indicated today--

5 MRN: 5 Patient Name: TEST, PATIENT T DOB: 1/5/1985 3/4/ :00:00 AM Provider: MALONE 3/21/2471 Visit Barrier: Multiple Late Arrivals Score PHQ2 Depression Assessment Over the past 2 weeks, how often have you lost enjoyment or taken little interest in your usual activities? Over the past 2 weeks, how often have you felt down, depressed, or hopeless? * Choices: 0=Not at all 1=Several days 2=More than 1/2 the days 3=Nearly every day * Add score of 2 questions and enter total. If score equals 3 or more, flip this page over and have patient fill out PHQ9. Was PHQ9 given to patient? Score A1c>9%, not on insulin * Diabetes Care Assistant should see this patient. * Start insulin today? Colon Cancer Screening Due * Last screening is out of date * Colonoscopy or FOBT ordered today? If no, R=refused, C=contraindicated, D=delay, N=not indicated

6 MRN: 6 Patient Name: TEST, PATIENT T DOB: 1/6/1985 3/4/ :00:00 AM Provider: MALONE 3/22/2471 Patient Needs: Interpreter Score --No prompts indicated today-- Cessation Counseling Indicated Cessation counseling provided (by CA or PCP)? IMC cessation class or NC Quitline Brochure given? Cessation medications addressed with patient?