Why Do I need an Annual Wellness Visit? To Our Medicare Patients: Medicare covers once a year wellness exam. There is no deductible, copay or coinsurance with your wellness visit. Medicare is very specific about what a wellness exam includes and excludes. Which means that the wellness exam is different from a yearly physical exam. For example, an actual physical exam is not required for your wellness visit. While at your visit here are some of the topics that the provider will go over: Review of health risk Height, weight, BMI, and blood pressure Depression screening Daily living, fall risk, and home safety Advance directive Wellness, weight loss, physical activity, tobacco use, and nutrition. We do appreciate the trust you have placed in us to take care of your health care needs and hope that you will take advantage of this benefit, and work with us in creating your personalized prevention plan. Sincerely, Internal Medicine Staff
HEALTH SERVICES OF CLARION, INC 121 DOCTORS LANE CLARION, PA 16214 Nutrition Checklist Nutritional Health Determination Check the number in the Yes column of each statement that applies to the patient. Take appropriate action according to the TOTAL SCORE. 1. I have an illness, condition, or wound that made me change the kind and/or amount of food I eat. 2. I eat fewer than 2 meals per day. 3. I eat few fruit or vegetable or milk products. 4. I have 3 or more drinks of beer, liquor, or wine almost every day. 5. I have teeth or mouth problems that make it hard for me to eat. 6. I don t always have enough money to buy the food I need. 7. I eat alone most of the time. 8. I take 3 or more prescriptions or over-the-counter drugs a day. 9. Without wanting to, I have gained or lost 10 pounds in the last six months. 10. I have physical difficulties to shop, cook, and feed myself. 11. I drink less than 4-8 glasses of fluid each day. YES NO Actions: Total: 0-2 points = no risk No action needed 3-5 points = moderate Improve eating habits and lifestyle. Adjust nutrition support by providing a supplement or instant breakfast. 6 or more points = high Establish a plan of care to meet the needs of the patient.
Patient: The Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Use the following scale to choose the most appropriate number for each situation: **Date Epworth Sleepiness Scale Completed: Situations 0 = No chance of dozing 1 = Slight change of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Chance of Dozing Sitting and Reading 0 1 2 3 Watching TV 0 1 2 3 Sitting inactive in a public place (eg. a theater or a meeting) 0 1 2 3 As a passenger in a car for an hour without a break 0 1 2 3 Lying down to rest in the afternoon when circumstances permit 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after a lunch without alcohol 0 1 2 3 In a car, while stopped for a few minutes in traffic 0 1 2 3 Interpretation of Epworth Sleepiness Scale Total Score: 0-9 Considered normal for majority of patients. This does not rule out a possible sleep disorder. If symptoms are consistent with OSA, referral to a Sleep Specialist should still be considered. 10-Plus Considered indicative of pathological sleepiness. Referral to a Sleep Specialist suggested. 24 Test Maximum.
NAME: Pain Scale Assessment How much are you bothered by pain right now? 1 NOT AT ALL [happy face] 2 A LITTLE [sort of happy] 3 MODERATELY [no expression] 4 QUITE A BIT 5 EXTREMELY [very sad]
Questions Where is your pain What do you think causes your pain? Which word(s) describe your pain? sore burning heavy cramping sharp aching dull stinging shooting tingling pressing (another word?)
PATIENT HEALTH QUESTIONNAIRE (PHQ-9) Name: Start Time: Date: Mothers name: (Check if using for maternal screening) Over the last 2 weeks, how often have you been bothered by any of the following problems? Choose an answer of Not at all, Several days, More than half the days, or Nearly every day. Several More than Nearly Not at all days half the days every day 1. Little interest or please in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself or that you are failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed. Or the opposite Being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead, or of hurting yourself in some way 10. If you have checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? (Healthcare professional: For interpretation of TOTAL, Please refer to accompanying scoring card.) Not difficult at all Somewhat difficult Very difficult TOTAL: Extremely difficult Depression Screening Result: Positive Negative
Internal Medicine ***FALL RISK ASSESSMENT IS TO BE COMPLETED ON ALL PATIENTS AGED 65 YEARS AND OLDER*** Doctor, Am I at Risk for Falls? About 11.5 million bone fractures occur in the United States each year. Hip fractures are increasing out of proportion to the aging population. Half of those who have fallen will fall repeatedly. Of those who have had a bone fracture, 40% cannot walk independently and 20% have a permanent disability. There is a higher mortality rate for men who have bone fracture than for women. Talk to your doctor and discuss your risk of falls. Together, you and your doctor can help prevent injuries from falls. Check Y (for Yes) or N (for No) next to each question below. Give the completed form to your doctor at your next visit. In the past 12 months, I Y N Fell two or more times Y N Took medication that caused me to feel dizzy or light headed. Y N Y N Took 9 or more different medications. Was injured by a fall that limited my regular activities for a least one day. Y N Saw a doctor because I had a fall. Y N Stopped some of my regular activities. Y N Y N Found it to be hard to climb stairs or walk a short distance. Have been taking calcium supplement regularly. If Yes, how much per day: Y N Had trouble getting up from a soft chair. Y N Have had my labs done to check my Vitamin D levels Y N Y N Have been unable to stand on one foot for 12 seconds without losing my balance. Danced, exercised, or practice Tai Chi at least 3 times a week. Y N Trouble with my eyesight. Y N Had my home checked for any dangers and modified as needed. Y N Felt dizzy or light headed after a big meal.
****Urinary Incontinence Assessment is to be completed on FEMALE patients aged 65 years and older.**** Urinary Incontinence Patient Assessment Questionnaire Y N Have you ever experienced any involuntary leakage of urine? Y N Does the loss of urine ever keep you from leaving your home? How often do you urinate during the daytime hours? 1-2 times 3-5 times More than 5 times How many times do you get up to urinate (or experience loss of urine) at night? 1-2 times 3-5 times More than 5 times Y N Do you ever have to schedule trips, social events, or errands around your toileting schedule? Y N Did you ever have to change your intake of fluids to avoid accidents? Y N Did you find that you must use special pads or other devices to protect yourself in case you do leak urine? Y N Have you ever noticed blood in your urine? Y N Do you have any burning or pain when you pass urine? Y N When you try to urinate, does it take you a long time to get started? Y N Is your urinary stream as strong as it ever was? How quickly must you get to the bathroom after you experience the urge to urinate? Right away I can wait, but a very short time I can wait until it is convenient Y N Can you stop urinating after you have started? Y N Do you ever leak urine upon coughing, sneezing, laughing, or when you stand up?
ADVANCE DIRECTIVE DECLARIATION I,, being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm settled commitment to refuse life-sustaining treatment under the circumstances indicated below. I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of dying if I should be in terminal condition or in a state of permanent unconsciousness. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment. In addition, if I am in the condition described above, I feel especially strongly about the following forms of treatment: I DO I DO NOT want cardiac resuscitation. want mechanical respiration. want feeding tube. want other artificial or invasive form of nutrition (food). want other artificial or invasive form of hydration (water). want blood or blood products. want any form of surgery. want any invasive diagnostic tests. want kidney dialysis. want antibiotics. want chemotherapy. want radiation therapy. want pain control. want other: I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatment. Other Instructions: I DO I DO NOT want to donate my organs upon death. want to designate a surrogate to make medical treatment decisions for me if I should be incompetent in a terminal condition or in a state of permanent unconsciousness. Surrogate (name and address): Substitute Surrogate (name and address): This declaration reflects my decision to accept or refuse life sustaining treatment. I certify that I have received an explanation of each item listed above and understand the consequences of accepting or refusing such medical treatments. This advanced directive order may be modified at anytime by a new advanced directive order signed by the patient or durable power of attorney and the physician. I choose the following: My Power of Attorney must follow these instructions. These instructions are only guidance. My Power of Attorney shall have final say and may override any of my instructions. I do not wish to appoint a Power of Attorney, these instructions must be followed. My Power of Attorney: Name: Relationship: Address: Home Phone Number: Work &/or Cell Phone Number: Alternative Power of Attorney: (If above is unable to serve.) Name: Relationship: Address: Home Phone Number: Work &/or Cell Phone Number: I made this declaration on Your Signature: Address: The above named individual or a person on behalf of and at the direction of the individual knowingly and voluntarily signed this writing by signature or mark in my presence. Witness's Signature: Address: