Annual Wellness Visit Form 6 Initial G48/Subsequent G49 (circle one) Subjective: Past Medical History (mark X to confirm and note duration for chronic conditions only) Conditions Yrs Conditions Yrs Others: Medication Review Last 6 Months (reviewed 59F/reviewed & reconciled 6F) Taken Taken Other Drugs Taken Drug Name For Drug Name For List: For Allergies: Social History (including diet and physical activities): Pertinent Family History: Substance Abuse (Drug/Alcohol): Discussion of Advance Directive: Yes No Comment: (Disscussion Code58F/Plan present in medical record Code57F) List of Specialist involved in member's medical care: Eye Care Professional Gastroenterologist Send Completed Form to Fax: (56) 66-8845 Rev. 5/6
Vital Signs: BP: Temp: Ht: Wt: BMI: Pulse Ox: egfr: Physical Examination Normal Abnormal Describe Findings General Skin HEENT Neck Heart Lungs Abdomen Musculoskeletal Neurologic (Consider RAPID PC + PHQ9) Vascular Lymphatic Extremities Rectal/GU Individual Care Plan: Indicate whether the patient needs the item (Yes) or if they have already had it (No) and the date received. Keep form on file and provide member with a copy. Social Marital Status: Married Divorced Single Transportation: Yes No Caregivers: Yes No Living Arrangements: Yes No Recreational Activities: Yes No Tobacco Cessation Date: / / Tobacco Cessation Counseling (ICD F7., CPT G46 (cessation counseling) Pain Screening Pain severity quantified: Yes pain present (5F) Pain severity quantified: No pain present (6F) Nutrition BMI (Code Z68.XX) : Hemoglobin: Serum Albumin: Recent Weight Change: Yes No Dentures: Yes No
Functional Status Assessment (code 7F) (does patient need assistance with:) Ability to Take Medication: Yes No Patient getting refills on time?: Yes No Feeding: Yes No Grooming: Yes No Toileting: Yes No Continence: Yes No Ambulation: Yes No Risk for Falls: Yes (codef) No (code F) Bladder Incontinence: Yes No if yes Treatment within past 6 months: Psychological Assessment Feeling Down: Yes No Sleep Disturbance: Yes No History of Depression: Yes No Substance Abuse: Yes No Advance Direction on File: Yes No (F) Cognitive Functioning Oriented: Yes No Immediate Recall: Good or Poor Delayed Recall: Good or Poor Confused: Mostly At times Not at all Memory Deficit: Yes No Inappropriate Behavior: Yes No Ask patient to draw hands to read minutes after 8 (or minutes after ). Case Management/Coordination Risk of admission to hospital: Yes No Risk of placement to SNF: Yes No Referral to Case Mgmt.: Yes No Referral to Disease Mgmt.: Yes No
Preventive Screening Checklist check if patient needs the Tx Date (Yes), If they have had the Tx, check Needs? Done Frequency (No), and indicate date performed Yes No (Req'd) Flu Vaccine (Current G8/previously 44F) / / Yearly between Sept. - March Pneumonia Vaccine (all > age 65) / / Once a lifetime (current:g9/previously G848) Glaucoma screening (> age 65 code Z.5) / / Yearly by eye professional Colonoscopy screening: (all > age 5) / / FOBT(Fit Test): annually(code Z.) OR / / Flex Sig(code G4): every 4 yrs OR / / Colonoscopy(code G5): every yrs Prostate Cancer Screen(Digital or PSA) / / Annually (male > age 5) Patients 65 yrs and older: Ask if they have urinary problems / incontinence / / Annually and advised or refer as appropriate Abdominal Aortic Aneurysm (AAA) Screening (Male members 65 and older / / Once in a lifetime who have smoked > cigarettes in a lifetime, have CV, and family history) Abdominal Ultra Sound Female Only Bone density test(dexa SCAN) (female>67 with fracture) 6 months / / Once every yrs for patients at risk for after hip fracture OR on medication osteoporosis. to treat or prevent osteoporosis. Mammogram (Age 5-74) years, (Z.) Yes (G) No Date or Not Applicable Member with Cardiovascular Disease Patients with cardiovascular conditions. LDL-C in Current Year (control < mg/dl) / / Annually On beta blockers for at least 6 months from discharge if hospitalized and / / Annually discharged with diagnosis of AM previous - current year Member with Diabetes HbAC lab (control < 7.)(code 48F-5F) / / Annually Retinal eye exam (code F-4F) / / Annually LDL-C lab(control < mg/dl)48f-5f / / Annually Blood Pressure < 4/9 (74F-78F) / / Each Visit Micro albumin test in current year OR patient on ACE or ARB in previous year / / Annually 4
Members with Hypertension Blood Pressure < 4/9 (74F-78F) / / Each Visit Member with Rheumatoid Arthritis Patients with diagnoses of RA trial of (DMARDs) / / On RA meds Members with COPD Spirometry test to confirm diagnosis / / Yearly PHQ9 Risk for Depression Screening: Please complete the following questionnaire. Over the last two weeks, how often have you been More than bothered by any of the following problems? None Several half the Nearly every (Circle number to indicate your answer) days days day. Little interest or pleasure in doing things. Feeling down, depressed, or hopeless. 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 add columns: (Healthcare Professional: For interpretation of TOTAL, TOTAL:. If you checked off any problems, how Not difficult at all difficult have these problems made it for Somewhat difficult you to do you work, take care of things at Very difficult home, or get along with other people? Extremely difficult Depression Severity by Total Score: -4 Minimal 5-9 Mild -4 Moderate 5-9 Moderately Severe -7 Severe *75F Depression Screening *F. major depressive disorder, single episode, mild * F.8 other depressive episodes * F. MDO, single episode, moderate *F.9 MOD, single episode, unspecified * F. MDO, single episode, severe without psychotic features *F. MDO, single episode, severe with psychotic features 5
ICD Code or Diagnostic Description Assessment Planning Provider Signature and Credential: Date: Send Completed Form to Fax: (56) 66-8845 6