Annual Wellness Visit. Name
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1 Annual Wellness Visit Trophy Club Family Medicine (817) rev 12/15 staff use only: Chart number: IPPE Initial AWV subsequent AWV Name Birthdate / / Date / / The purpose of the annual wellness visit (AWV) is to develop or update a personalized prevention plan to prevent disease and disability based on your current health and risk factors. This involves going over your medications, past social, medical, surgical history, the other providers that you see, as well as detection of major risks such as depression, falls, cognitive impairment. Screening for appropriate preventive services will also be discussed. The zero co-pay AWV covers this assessment. However it is NOT a physical exam. Other special concerns that you have will need to be discussed at a separate visit for this visit to remain zero co-pay. t all recommended services will be covered 100%. Please fill the form out as completely as possible. Any list that you provide and reference is fine. It is very helpful if you bring your bag of medications and supplements. Allergies or reactions to medications, or other agents Medication Reaction or side effect Medication Reaction or side effect Please list ALL current medications, vitamins, herbs or non-food supplements Medication Dose Frequency Medication Dose Frequency Any chronic or recurring conditions, hospitalizations, surgeries, or major illnesses? If you have been to any specialist that we need to be aware of? If so, then please sign release so that we can obtain reports.
2 Personal and Family history Please indicate anyone who had any of the following conditions. Please specify who had it: brother, maternal grandmother, etc. Go up to 2 nd generation only. Medical condition self mom dad sibling child Other relative Medical condition self mom dad sibling child Other relative Addictions Heart attacks Alcoholism Heart disease Anxiety High blood pressure Anemia (chronic) High cholesterol Asthma Kidney disease Bipolar Lupus / autoimmune Birth Defects Mental illness: Cancer, colon Migraine headaches Cancer, breast Osteoporosis Cancer, other: Rheumatoid arthritis Depression Seizure disorder Deep vein blood clot Stroke Diabetes Thyroid disorder Genetic diseases Deceased (at age) Glaucoma Other: Social history and habits: Home: rented owned nursing home other Tobacco use Current smoker. Want to quit?: Former smoker, quit date: Never smoked Other tobacco: pipe cigar snuff chew Total history of all tobacco use: Average packs/day:. #of years:. Alcohol use Drink alcohol regularly?. Average number drinks/week: Is drinking a concern for you or others? Any tattoos? History of blood transfusion? Religion?
3 Drug use Have you ever used recreational drugs? Still using? Average daily caffeine use # coffee: (6oz = 1 serving) # tea # cans of soda # energy drinks # other. Diet: Average servings (½ cup = 1 serving) of fruits/vegetables daily: Exercise: Do you get regular exercise? Is it vigorous (huff, puff, and sweat)? How much of what exercise: Current occupation: Occupational hazards: Hobbies/activities: Education completed: grade HS trade college masters doctorate Marital status: single married divorced separated widowed/er other Do you feel safe? Advance Directives: Please circle which one(s) you have: living will, Medical Power of Attorney, out of hospital DNR, Directive to Physicians and Family or Surrogates Form, Declaration for Mental Health Treatment, Statutory Durable Power of Attorney), other Sexually active Sexual history Sex partners are male female Women's gynecologic history: # pregnancies: # abortions: # miscarriages: # c-sections # vaginal deliveries: Last menstrual period Ever had an abnormal pap? Cancer Screening / Immunizations Last colonoscopy Last bone density scan Influenza Tetanus (Td/Tdap) Date Last mammogram Last stool test for blood Pneumovax (pneumonia) Zostavax (shingles) Date
4 Screening questions Have you fallen two or more times in the past year Are you afraid of falling? Can you get to places out of walking distance without physical help? Example, getting to grocery store or to doctor's office. Do you always wear your seat belt when you are in a car? Do you have trouble keeping track of your medications? Over the past 2 weeks, have you felt down, depressed or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things? Need help with phone, transportation, shopping, preparing meals, housework, laundry, medications, or managing money? Any rugs in hallways, lack grab bars in bathrooms, lack handrails on stairs or poor lighting? Any hearing difficulties? During the past month, how much have you been bothered by emotional problems? During the past month, has your physical or emotional health limited your social activities with others? Any issues in past month with dizziness/falling when getting up? Any issues in past month with sex? Any issues in past month with trouble eating? Any issues in past month with teeth/dentures? Any issues in past month with fatigue? Any issues in past month with using telephone? During the past month, how much pain have you had? In the past month, was someone available to help if you needed and wanted help? How have things been going for you in the past month? pain Mild pain Moderate Severe Very severe, plently Great!, quite a bit Pretty good How would you rate your heath in general? Great! Pretty good In past month, what is the hardest activity that you can do for at least 2 minutes? Very heavy, some, a bit t at all So-so t good Horrible So-so t good Bad Heavy Moderate Light Very light Any issues in driving your car? Rarely Sometimes Don't drive
5 Advanced Directives: Why let other guess about what you want when you can tell them in advance? This includes but is not limited to living will, Medical Power of Attorney, out of hospital DNR, Directive to Physicians and Family or Surrogates Form, Declaration for Mental Health Treatment, Statutory Durable Power of Attorney. Colonoscopy: the purpose of colonoscopy is to screen people for colon pre-cancers that occur in form of polyps. There are alternatives to colonoscopy for screening, but colonoscopy is considered the best test available. It is important to screen for these when there are easily treatable and no symptoms are present. If one waits until one feels bad, then it is often too late. Alternate colon cancer screening: include air-contrast barium enema, virtual colonoscopy, flexible sigmoidoscopy, fecal occult blood screening, DNA-based fecal screening. These tests are less invasive than colonoscopy. However, they still require the same annoying bowel preparation. If anything abnormal is found, then colonoscopy will be required as the follow-up test. Thus, for abnormal test results, high risk patients, colonoscopy is still preferred. However, for selected patients, alternate colon cancer screening may be done if colonoscopy is not possible for risk or cost considerations. Depression: This is not just the blues, but untreated depression significantly increases the risk of heart disease, stroke, and generally all cause mortality. easy cure as medications are an imperfect treatment and do not work 100%. Treatment is best accomplished by combination of medication, therapy, and lifestyle adjustments. DEXA (Bone Density scan): This test is needed in all at risk patients and is repeated every 1-2 years. Female gender, low vitamin D, lack of weight bearing exercise, underweight status, low estrogen or testosterone levels, certain ethnic groups, long-term or frequent exposure to steroid are considered risk factors. Diabetes: Risk of diabetes unfortunately goes up with age. Waiting until one feels bad is not a good strategy as it is too late - early diabetes is often asymptomatic. Annual check of the a1c (3 month average glucose) is important in early detection. Prevention is best accomplished by diet low in sugars and carbohydrates (bread, rice, pasta, potatoes), more vegetables (other than potatoes), and routine exercise. Diet: As we age, our calorie needs generally decline due to less physical activity. However, the nutrient requirements still generally remain the same. It is important to get a well balanced diet that is high in protein, lots of fresh vegetables and fruits to get vitamins and minerals naturally, and plenty of water intake for good hydration. Unfortunately, no good studies show that multivitamins are useful. Natural intake of 4-6 servings daily (about 2-3 cups) of vegetables and fruits is much more beneficial for overall health. Exercise: Best way to keep the doctor away is not an apple but routine moderate exercise. Start by going for a walk and stretching for 15 minutes 3-5 times per week. Then gradually increase and add in some light weights and core/abdominal exercises. There is no limitations: sports, yoga, calisthenics, spin classes, dancing, hiking, even vigorous yard work counts. Goal is 3 hours per week minimum over at least 3 days. Flu vaccine: Contrary to many myths, this vaccine does NOT cause flu. It trains your immune system to fight off flu for the upcoming season. We give high strength flu vaccine to
6 better boost your immune system. Studies have also shown that flu vaccine decreases risk of dying from unrelated diseases like heart attack and stroke. Even a mild flu is no little matter! Hearing: Medicare generally does not cover hearing aids well. However, good hearing is not just needed for good quality of life but to be able hear and respond to dangers. If your loved ones complain, then please get tested. High risk medications: there is a long list of medications that is considered high risk due to recognized increase risk in death, disability, and dementia (for various causes). This list (not exhaustive) includes most sleeping pills, tranquilizer type anti-anxiety pills, narcotics, most muscle relaxers, etc. Even OTC benadryl/diphenhydramine is risky! Insomnia: This is an extremely common problem that afflicts everyone eventually. However, it generally gets worse with aging due to more broken-up deep sleep and less deep sleep. Thus, one may get plenty time of sleep, but poor quality. Treatment should be focused on NON-medication treatment as many sleeping pills increase risk of death, dementia, and falls. Mammography: Just because you reach menopause and the periods stop does not mean that breast cancer risk drops. In fact, it keeps rising. It is important to do routine self-breast examinations, breast exams (not part of AWV) and annual mammograms. Smoking cessation: Quitting smoking is very hard. Nicotine is not safe like water but any nicotine replacement is much better than smoking. You will feel the difference within a week. Consider the gum, lozenge, patch, inhaler, or even the e-cigarette. Medications are available to help. Stress reduction: Just because you are retired or about to retire does not mean that there is no stress. High stress living is just as bad as major medical conditions such as diabetes and heart disease. Important part of holistic medicine is to care for the mind and spirit. Please make sure to engage in fun activities, hobbies and to socialize. Options are limitless and include: Library: not just for books. They have fun educational classes, videos, and even free internet for those who do not have it at home. Community recreational center: tons of activities going on all the time for free or nominal fee. Cultural centers: Texas is not all about BBQ, cows and donuts. We have plenty of local museums, zoos, aquariums, theaters, farmer's markers, local breweries, comedy clubs, boating, etc. online forum to plan physical local meetings with people of similar interests. Interests can range from athletic (like running, sports), to technical (computers, marketing), to lifestyle (foodies, parenting, singles), to special. Local park and lakes: go for a walk, picnic, feed the ducks (beware of geese!). Fort Worth Botanic Garden is wonderful and FREE (parking and admission). Church/temple/synagogue/religious center: it is just as important to care for the soul as it is to for the body. Please be involved in a community to help and be helped. Volunteer: There is always a need for able bodies. If you are bored and want to feel needed, then please volunteer at local religious center, food bank, animal shelter, etc. Livingsocial, Groupon, AmazonLocal, etc: looking for something to do? Try these for ideas and deals on local events. Try making stained glass, pottery, painting, cooking classes, water sports.
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