MEDICARE ANNUAL WELLNESS VISIT
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1 MEDICARE ANNUAL WELLNESS VISIT FAMILY MEDICINE CENTERS OF SOUTH CAROLINA, LLC Springwood Lake Midtown Woodhill Saluda Pointe Lake Murray Name: Ethnic Background: Race: Age: Sex: Marital Status: PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT YOUR OWN MEDICAL HISTORY: (1) Chronic Medical Problems (i.e.: Diabetes, Hypertension, Arthritis, Heart Disease, Thyroid, Asthma, Depression, etc.): (2) Current Medicines & Supplements (i.e.: Heart drugs, Inhaler, Insulin, Antacid, Hormone, Blood Thinner, Vitamins): (3) Serious Illnesses (i.e.: Hepatitis, HIV, Ulcer, TB, Kidney Stones, Meningitis, Pneumonia, Heart Attack, Stroke, etc.): (4) Major Injuries (i.e.: Fracture, Burn, Concussion, Gunshot, Torn Cartilage, Ruptured Spleen, Ruptured Disc, etc.): (5) Surgery (i.e.: Biopsy, Tonsils, Appendix, Gall Bladder, Hernia, Coronary Bypass, Hip, Knee, Colonoscopy, etc.): (6) Hospital Admissions (i.e.: Serious Illness, Bad Injury, Surgery, Pregnancy, Nervous Breakdown, Diagnostic Work, etc.): (7) Physical Impairments (i.e.: Deafness, Eye Glasses, Dentures, Cane, Colostomy, Birth Defect, Amputation, etc.): (8) Allergies/Drug Reactions (i.e.: Insect Bites, Hives, Asthma, Hay Fever, Sinus, Eczema, Drug Reaction, etc.): (9) Habits (i.e.: Smoking, Alcohol, Caffeine, Laxatives, Nasal spray, Pain Medicine, Illegal Drugs, etc.): (10) Social Background (i.e.: Education, Employment, Marital Status, Children, Military, Hobbies, etc.): (11) Do you have any medical problems now that require prompt medical attention? (12) Please list the doctors, other medical providers and suppliers you have used within the past 3 years (i.e.: Podiatrist, Specialists, Gynecologist, Psychiatrist, Optometrist, Chiropractor, Physical Therapist, equipment supplier, etc.):
2 FAMILY MEDICAL HISTORY LIST ANY DISEASES THAT OCCUR IN MULTIPLE BLOOD RELATIVES: END-OF-LIFE PLANNING YES NO (1) Do you have a written Will which conveys ownership of your property after your death? (2) Have you appointed an Executor to manage your estate after your death? (3) Do you have a Living Will or some other written end-of-life medical directives? (4) Have you appointed a Health Care Agent who can make medical decisions for you just in case you re not able to do so in the future? (5) Have you read the 5 Wishes for End-of-Life Planning? HEALTH & SAFETY RISKS YES NO (1) Do you have any safety concerns in your home, workplace, or community? (2) Do you engage in exotic travel or risky activities (i.e.: motorcycle, surfing, skiing, etc.)? (3) Do you fail to wear your seat belt regularly while in a vehicle? (4) Do you have a problem with poor balance/coordination or frequent falls? (5) Has your vision gotten worse lately? (6) Has your hearing gotten worse lately? (7) Do you have chronic or severe pain not well-controlled by your current treatment? (8) Do you have any foot, neck, back or joint problems that impair your function? (9) Do you have sleep problems, bad snoring, or bothersome daytime drowsiness? (10) Have you had problems with bowel or bladder control? (11) Do you have a problem with your sexual function which is bothersome to you? (12) Do you currently smoke or use tobacco? (13) Do you consume more than 2 drinks of liquor, wine or beer per day on the average? (14) Has your weight increased or decreased more than 20 pounds over the past 2 years? (15) Do you get less than 2 hours of exercise per week? MENTAL HEALTH STATUS YES NO (1) Have you or others noticed that your memory or thinking ability are worse lately? (2) Have you or others noticed that you seem to be tense, nervous or anxious lately? (3) Do you tend to worry a lot lately?
3 PATIENT HEALTH QUESTIONNAIRE 9 Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle your answers) NOT AT ALL SEVERAL DAYS MANY DAYS EVERY DAY (1) Little interest or pleasure in doing things (2) Feeling down, depressed or hopeless (3) Trouble falling or staying asleep, or sleeping too much (4) Feeling tired or having very little energy (5) Poor appetite, or overeating (6) Feeling bad about yourself, or feeling that you are a failure (7) Trouble concentrating on things (such as the newspaper or TV) (8) Moving or speaking so slowly that other people might have noticed, or being very fidgety and restless (9) Thought that you would be better off dead or might hurt yourself Total Score: If you have any of these problems, how have these problems made it for you to do your work, take care of tasks at home, or get along with other people? Not at all Somewhat Very Extremely Developed by Drs. Robert L. Spitzer, Janet B. W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer, Inc. No permission required to reproduce, translate, display or distribute.
4 ACTIVITIES OF DAILY LIVING CHECK YOUR CURRENT LEVEL OF FUNCTION FOR EACH OF THE DAILY LIVING ACTIVITIES LISTED BELOW: Activities Don t Need Help Sometimes Need Help Must Have Help Bathing Dressing Grooming Dental Care Using the Toilet Transferring Walking Climbing Stairs Eating Cooking Shopping Reading Managing your Medicines Using the Phone House Work Doing Laundry Driving Managing your Finances PREVENTIVE MEDICINE MEASURES YES NO (1) Have your Blood Sugar and Cholesterol been checked within the past 2 years? (2) Has your stool been checked for blood within the past year? (3) Have you had a screening Colonoscopy for Colon Cancer within the past 5 years? Where (4) Have you had a Complete Physical Examination within the past 2 years? (5) Have you had an eye exam within the past 2 years? Where (6) Have you seen a dentist within the past 2 years? (7) Have you had Pneumococcal (Pneumonia) Vaccine within the past 10 years? (8) Have you had Influenza (Flu) Vaccine within the past year? (9) Have you had a Tetanus booster within the past 10 years? (10) Have you ever had Shingles Vaccine? (11) If male, have you had a PSA test for Prostate Cancer within the past 2 years? (12) If female, have you taken Osteoporosis medicine with the past year? (13) If female, have you had a DEXA Bone Density Scan within the past 2 years? (14) If female, have you had Mammograms within the past 2 years? (15) If female, have you had a Pap Smear within the past 2 years?
5 VITAL SIGNS & VISUAL ACUITY Weight FAR VISION Height Corrected BMI Uncorrected Pulse Right Eye / BP Left Eye / Resp Both Eyes / Temp ifob PROVIDER CHECK-LIST (1) Review Personal Medical & Social History (2) Review Family Medical History (3) Review End-Of-Life Planning (4) Review Health & Safety Risks (5) Review Mental Health Status (6) Review Activities of Daily Living (7) Review Preventive Medicine Measures (8) Provide Patient Education and Counseling (if appropriate). (9) Schedule a complete Physical Exam or regular office visit (if appropriate). (10) Schedule Preventive Medicine services such as DEXA, Mammograms, Pap Smear, Colonoscopy, etc. (if appropriate). (11) Refer to other medical providers within or outside of the Practice (if appropriate). (12) Provide Nutrition Guidelines. (13) Personal Health Care Plan for the next 3 years. (14) Provide Preventive Medicine Check List. IPPE IAWV SAWV Physician Signature: Date: Revised 12/15/2015
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