To make your Annual Wellness Visit as helpful as possible, we ask that you do the following:
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- Agatha Stevenson
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1 Aspen Medical Group Crista Keller, M.D. Megan Press, M.D. Katherine Johnson, NP-C Susan Esmond, PA-C E. Kendrick Lane, PA-C To our valued Medicare Patients, Medicare will now be covering a free annual wellness visit. This is a new benefit for our senior patients. The Annual Wellness Visit is different from a traditional routine physical because it screens for risks specific to the senior population (such as fall prevention). Your annual wellness visit is the only preventative visit that Medicare will reimburse. We ask, therefore, that this visit be limited to developing your personalized prevention plan a written list of tests and interventions that your provider recommends specifically for you. If you do have a more urgent concern (such as chest pain, problems urinating, joint pain, etc.), we request that you schedule a separate appointment to address this. Copays and deductibles will apply for any care that is not part of the Annual Wellness Visit. To make your Annual Wellness Visit as helpful as possible, we ask that you do the following: Compete the attached Annual Wellness Visit form before your appointment and make sure to bring it with you. Your visit may need to be rescheduled if you do not have your completed form with you. Bring documentations of any vaccinations you have received Bring in copies of any advanced directives or medical durable power of attorney forms. Please arrive minutes early to allow our medical assistants time to check your vital signs, vision and hearing. We look forward to seeing you soon for your Annual Wellness Visit! Please call us with any questions or concerns at Sincerely, The Providers and Staff of Aspen Medical Group
2 Medicare Wellness Visit Patient Questionnaire Provider Initials Name: Today's : / / of Birth: / / Gender: Male Female Race (circle): Caucasian African American Latino Other: Past Medical History: Please list all major medical problems (i.e. high blood pressure, high cholesterol, diabetes, heart disease, asthma, sleep apnea, etc.): Current List of Specialists You See: Name Specialty Reason Please list any surgeries you have had including dates: List medications and dose you are on: (circle) See attached list Medication: Dose: Frequency: Medication: Dose: Medication: Dose: Drug Allergies: Have you ever used Tobacco? (circle) No Yes Quit If yes, what type (circle) Cigarettes Chew Pipe Cigar packs per day for the last years Alcohol use? drinks per day week month Recreational drug use? (circle) No Yes Type(s): What is your (current/former) occupation? Who lives with you at home? Do you exercise? No Yes If yes, times per week Type: Are you on a special diet? No Yes If yes, why? Do you always fasten your seat belt? No Yes Do you wear sunscreen? No Yes Do you have any problems performing dressing, feeding, toileting, or grooming? No Yes Do you need help with shopping, food preparation, housekeeping, taking medicine or managing finances? No Yes
3 Have any of your family members had the following health problems? Check ALL that apply and state WHO in your family had each problem. None Thyroid Problems Heart Disease Stroke High Blood Pressure Bleeding Disorder Diabetes Osteoporosis Asthma Cancer, Type Have you had any of the following in the last 2 weeks? Check all that apply. I have not had any of these problems Constitutional Recent weight change Fever Weakness Fatigue Gastrointestinal Heartburn Nausea/vomiting Diarrhea Abdominal pain Endocrine Hot flashes Excessive thirst Heat/cold intolerance HEENT Visual problems Hearing Problems Dry mouth Snoring Other Musculoskeletal Severe muscle pain Severe joint pain Other Hematological Easy bruising Cardiovascular Chest pain Varicose veins Blood clots Neurological Severe headache Numbness Tingling Immunologic Swollen lymph nodes Respiratory Chronic cough Wheezing Shortness of breath Oxygen use Skin Rashes New/changing moles Sores Lumps Psychiatric Depression Anxiety Other Do you have an Advanced Directive (Circle): Yes No Advanced Care Planning Consent: I consent to discuss end-of-life planning issues with my healthcare provider. (Circle): Yes No Patient/Guardian Signature
4 Medicare Annual Wellness Visit *** TO BE COMPLETED BY MEDICAL ASSISTANT *** Patient s Name: Exam: Height: of Exam: / / of Birth: / / Weight BMI: Medical History ( See AWV Pt Questionnaire d / / ) BP: Medications: ( See List) HR: SPO2: Family History (List positive results from AWV Questionnaire) *See Flow Sheet* Depression Screen (ask the following questions, circle the response) 1. Over the last two weeks, have you felt down, depressed or hopeless? No Yes 2. Over the last two weeks, have you felt little interest or pleasure in doing things? No Yes Hearing Loss Screen 1. Do you have trouble hearing the television or radio when others do not? No Yes 2. Do you have to strain or struggle to hear/understand conversations? No Yes Function Screen 1. Do you need help with preparing meals, transportation, shopping, taking you medicine, managing your finances, or other activities of daily living? No Yes 2. Do you live alone? No Yes Home Safety Screen 1. Does your home have throw rugs, poor lighting, or a slippery bathtub/shower? No Yes 2. Does your home LACK grab bars in bathrooms, handrails on stairs and steps? No Yes 3. Does your home LACK functioning smoke alarms? No Yes Visual Acuity: L 20/ R 20/ Whisper Test: Pass Fail Risk for falls Screen 1. Was the patient unsteady or take longer than 30 seconds during the timed get up and go test? No Yes Detection of Cognitive Impairment: No Yes Notes : Advanced Care Planning 1. Patient already has executed and Advance Directive? No Yes 2. If no, patient was given an opportunity to execute and Advance Directive today? No Yes 3. Physician statement This individual has the ability to prepare an Advance Directive. No Yes 4. Physician has completed a physician order for life-sustaining treatment, or similar document of reflecting the patient s wishes for an advanced care plan. No Yes 5. Physician is willing to follow the patient s wishes. No Yes Physician Signature
5 ASSESSMENT AND PLAN: 1. Annual wellness visit V70.0. Pt given written copy of recommended preventive measures below. F/u appt recommended in: Physician Signature Preventive screen (frequency) Bone Mass Measurements (every 24 months) Cardiovascular Screening Blood Tests (every 5 years) Lipid panel Cholesterol Lipoprotein Triglycerides Coverage Medicare patients at risk for developing Osteoporosis All asymptomatic Medicare patients (12-hour fast is required) Previously tested (If yes, when?) Scheduled for screenings (5 to 10 years) Colorectal Cancer Screening Flexible sigmoidoscopy (4 years, or once every 10 years after a screening colonoscopy Screening colonoscopy (every 24 months at high risk; every 10 years not at high risk) Fecal occult blood test (annually) Barium enema (every 24 months at high risk; every 4 years not at high risk) Diabetes Screening Tests (2 screening tests per year for patient diagnosed with pre-diabetes; 1 screening per year if previously tested, but not diagnosed with pre-diabetes or if never tested) Diabetes Self-Management Training (DSMT) and Medical Nutrition Therapy (Up to 10 hours of initial training within a continuous 12 month period; subsequent years up to 2 hours of follow-up training each year after initial year) Glaucoma Screening (annually for patient ins one of the high risk groups) Prostate Cancer Screening (annually) Digital rectal exam Prostate specific antigen test Screening Pap Tests and Pelvic Examination (annually if high-risk, or childbearing age with abnormal Pap test within past 3 years; every 24 months for all other women) Screening Mammography (annually) Vaccines Pneumococcal (once in a lifetime) Seasonal Influenza (once per flu season in the fall or winter) Hepatitis B (scheduled dosages required) Other: Medicare patients age 50 and up Screening colonoscopy: Those at high risk; no minimum age No minimum age for having a barium enema as an alternative to a high risk screening colonoscopy if the patient is at high risk Medicare patients with certain risk factors for diabetes or diagnosed with pre-diabetes (patients previously diagnosed with diabetes aren t eligible for benefit) Medicare patients at risk for complications from diabetes, recently diagnosed with diabetes or previously diagnosed with diabetes (must certify DSMT need) Patients with diabetes mellitus, family history of glaucoma, African-Americans age 50 and over, or Hispanic-Americans age 65 and up All male patients 50 or older All female Medicare patients All female patients 40 or older All Medicare patients May provide additional pneumococcal vaccinations based on risk and provided that at least 5 years have passed since previous dose Hepatitis B, if medium/high risk
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.) We look forward to your visit with us. We would like to provide you with infonnation that will be helpful to you in your interaction with our office. Please read this prior to your visit. OFFICE HOURS:
LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty
6. Do you have an Advance Directive or Living Will? Yes No These are written statements about how you want to be treated if you get very sick.
Adult Health History Name: First Last Name you like to be called: Today s Date: Date of Birth: Male Female Transgender Male to Female Transgender Female to Male Other Filling out this form Answering these
Patient/Guardian Signature Witness Signature
Today s Date Full Name Date of Birth Gender M F Social Security # Email * Home Address City State Zip Home Phone Work Phone Cell Phone Patient Employer Job Title Insurance Subscriber Subscriber Birthdate
INSURANCE INFORMATION FINANCIAL AGREEMENT PRIVACY POLICY (HIPAA) LIFETIME INSURANCE AUTHORIZATION
PATIENT INFORMATION: DATE: NAME (LAST, FIRST, MI) ADDRESS CITY, STATE, ZIP PHONE ALTERNATE PHONE BIRTHDATE SEX MARITAL STATUS SOCIAL SECURITY RACE/ETHNICITY (please circle): American Indian or Alaskan
Westoaks Orthopaedic Associates
Westoaks Orthopaedic Associates Name: Address: Patient ID #: Sex: M [ ] F [ ] Date of Birth: Social Security #: City, State, Zip: Email: [ ] Home [ ] Work [ ] Mobile [ ] Married [ ] Single Referring Physician:
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
Your Guide to Medicare s Preventive Services
Your Guide to Medicare s Preventive Services C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S This is the official government booklet with important information about: What disease
Integrated Medical Services (IMS) New Patient Registration Sheet
Personal Information Today s Date: Patient First Name: Initial: Last Name: DOB: Age: Social Security #: Email: Address: Street Apt # City/State/Zip Home Phone: Work Phone: Cell phone: Gender : M F Language:
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
Patient Intake Form. Patient Information. How did you find out about our office?
Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our
PRIMARY CARE ASSOCIATES MASS GENERAL WEST NEW PATIENT QUESTIONNAIRE
PRIMARY CARE ASSOCIATES MASS GENERAL WEST NEW PATIENT QUESTIONNAIRE Name: DOB: Date completed: Where have you received health care previously? Do you require a translator? Yes No Do you have any hearing,
TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD
TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD Please complete this form to the best of your ability and bring it to your Physician, Nurse Practitioner or Physician s Assistant for your physical examination.
Community Internal Medicine of Athens 1500 Oglethorpe Avenue Suite 200D Athens, GA 30606 Phone: (706) 389-3875 Fax: (706) 389-3876
Please Fill Out Completely: Community Internal Medicine of Athens Phone: (706) 389-3875 Fax: (706) 389-3876 Patient s Last Name First Name MI Social Security Number Date of Birth Age Gender Race Marital
PREVENTIVE CARE SERVICES Detailed descriptions
PREVENTIVE CARE SERVICES Detailed descriptions How often and what kind of preventive care services you need depends upon your age, gender, health and family history. Not all items on this list are covered
1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840
Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible