Health Assessment Section 1: (to be completed by Provider)

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Health Assessment Section 1: (to be completed by Provider) The HealthSmart Assessment provides a comprehensive evaluation of a member s health and wellness, relevant lifestyle issues, psychosocial and clinical problems and a physical examination that supports InHealth Cares wellness and prevention program. The physician will provide this assessment on an annual basis at the same time as the member s annual screening (adult and pediatric) to improve self-management of health and wellbeing. The primary care provider will provide a copy of this document to the insurer that can be faxed or mailed to: Our secure fax number is: 800-538-0372 Our mailing address: InHealth Mutual; 501 West Schrock Road, Suite 310; Westerville, OH 43081 NOTE: A copy of the Health Assessment Documents can be found on the Provider portal at www.inhealthohio.org Member Last Name: Address: DOB: / / Member ID: Email: Phone: RACE/ ETHNICITY/ BACKGROUND White Hispanic or Latino origin or descent Asian American Indian or Alaskan Native Black or African American Native Hawaiian or Pacific Islander Language Spoken: Have You Served In the Military? Yes No SUPPORT PERSON CONTACT INFORMATION Last Name: First Name: Relationship: Address: MEMBER DEMOGRAPHIC INFORMATION First Name: Phone: INTERDISCIPLINARY CLINICAL TEAM (IDCT) List all active providers NOTE: Please list the Provider performing this evaluation: Provider Name Provider Specialty Address City / State / Zip PAST HISTORY--(Include any chronic disease; medical/surgical and behavioral health) No Medical History New Past Chronic Current Management of Diagnosis Chronic Disease Medication Medication Medication Medication Medication Medication Medication Medication Medication Medication Email:

Page 2 of 5 PROBLEM LIST No Surgical Medical History Date First Modality (medication, therapies, Problem Next Evaluation Date Diagnosed etc.) MEDICATION LIST Prescription & Over the Counter (OTC) No Medication History Quantity Medication Dosage Refillable Reason Prescribed Limit/Frequency 1 1 1 1 1 FAMILY HISTORY Condition No Family History Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Cancer 1b. Type & Obesity Diabetes Kidney Heart Stroke PRESENT ILLNESS-- Please report chronic disease in this section Diagnosis Risk Factors Diagnosis Date Sister Brother

Page 3 of 5 ALLERGIES N Drug Allergies No Food and Allergies Drug Allergies Describe Adverse Reaction Food and Allergies Describe Adverse Reaction 4 SCREENING REVIEW MEN Last Rectal/Prostate Exam Y N PSA Y N WOMEN Last PAP smear Y N Mammogram (50 years of age) Y N Breast Exam (teaching self exam) Y N GENERAL BMI Y N Lipid/Cholesterol Screening Y N Colorectal Cancer (Colonoscopy) Y N ADULT VACCINATION Pneumococcal vaccine Y N Influenza Vaccine Y N TD/Tdap Vaccine Y N Y N PEDIATRIC (through age 18) MMR Y N Varicella Y N HepA Y N HepA Y N

Page 4 of 5 MANAGEMENT OF CHRONIC DISEASE (Leave blank if chronic disease is not applicable) Date Done in the current or previous calendar year? Diabetes Lipid profile Y N HbA1c Result: Y N Dilated retinal exam Y N Foot exam Y N Asthma Asthma Action Plan Y N Rescue meds Y N Long-term control meds Frequency of Use Cardiovascular Congestive Heart Failure (CHF) Y N Coronary Artery Disease Y N Echocardiogram Ace Inhibitor Y N Beta Blocker Y N Lipid Profile (LDL Cholesterol Screening) Y N Aspirin Y N COMMENTS NL ABNL Height ft. in Weight lb. BMI: BP: Pulse: Pulse Oximetry (if indicated) 2nd BP (if needed): Mental Status Verbally Coherent REVIEW OF SYSTEM NL ABNL EYES / HEENT - + Explain + Responses Normocephalic Glaucoma Pupils (NL: PERRLA) Cataract present: Left /Right/ Both EOMs Cataract removed: Left /Right/ Both Conjunctiva/lids Change in vision Diabetic eye disease h/o laser treatment to eye(s) Reason: NL ABNL - + Explain + Responses Teeth: If ABNL (select): edentulous/poor repair Thyroid problem Describe: Neck: (NL: no adenopathy) Parathyroid problem Describe: Trachea (NL: midline) Difficulty chewing Ears Difficulty swallowing NL ABNL RESPIRATORY - + Explain + Responses Lungs: Observation ABNL(select): increased E/ratio/labored resp/other Shortness of breath or Wheezing Lungs: Ausculation (NL: clear) ABNL (select): rates/rhonchi/wheezing Orthopnea NL ABNL CARDIOVASCULAR - + Explain + Responses Heart : Ausculation Select: irregular/murmur Angina Heart attack/mi date if known Heart procedure/surgery (select): Jugular venous distention, sitting (ABN: present) Angiogram/PCI/PTCA/CABG/Ablation/Valve replacement Peripheral edema (NL: not present or trace) Palpitations (select) Pacemaker/Internal Defibrillator Pulses/auscultation, carotid ABNL: bruit (select): Heart valve problems: R / L mitral/aortic/pulmonary/tricuspid Pulses/auscultation, femoral, ABNL: bruit (select): R / L Dyspnea on exertion Dyspnea lying flat at night (PND) Pulses, DP (if ABNL) (select): diminished R/absent R/diminished L/ absent L Swelling in legs/edema Pain in either calf while walking and does not go away until you stop walking? (consider diagnosing peripheral vascular disease, if positive) Pulses, PT (if ABNL) (select): Varicose veins diminished R / absent R /diminished L / absent L

Page 5 of 5 NL ABNL GASTROINTESTINAL - + Explain + Responses Ostomy Describe Special Diet Liver, spleen Anorexia Ascites (NL: not present) Bloating Abdominal aorta Indigestion Constipation Diarrhea Fecal incontinence Blood in stool/gi bleed Black stools Hemorrhoids Liver Disease Jaundice NL ABNL GENITOURINARY - + Explain + Responses Ostomy Describe: Kidney failure CVA Tenderness Erectile Dysfunction Male Genital Exam Urination at night Frequency Female Genital Exam Blood in Urine Urinary Hesitancy Urinary Incontinence NL ABNL MUSCULOSKELETAL - + Explain + Responses Joints If ABNL (select): rheumatoid/osteoarthritic/other Skin Ulcers (decubitus, etc.) Joint stiffness R: great toe/other toe/foot/ankle/bka/aka Joint pain L: great toe/other toe/foot/ankle/bka/aka Back pain Bil: great toe/other toe/foot/ankle/bka/aka Osteoporosis Fracture/Injury to limbs Skin (select): rash/plaque/bruising/tumor(s)/ulcers/necrosis ROM (NL:intact; full) Unexplained falls (indicate number in the last year): If excessive falls, your assessment of the member, and/or home environment appears to place member at risk, mark CPR #905 for Fall Risk Reduction Program. NL ABNL NEUROLOGICAL - + Explain + Responses Numbness Speech (ABNL (select): aphasia/dysphasia) Neuropathic pain If unable to perform foot exam give reason: Dizziness/Vertigo Ankle reflexes Rt (select): absent / present / increased Tremors Ankle reflexes Lt (select): absent / present / increased Phantom limb syndrome/pain Vibratory sense at ankle Trouble walking Monofilament x5 (ABNL: one or more locations with diminished sensation) Cerebrovascular even (select): Stroke/TIA If unable to perform monofilament exam give reason: Presence of (select): Hemiparesis/Hemiplegia/Paraplegia REVIEW OF SYSTEM NL ABNL NEUROLOGICAL (continued) - + Explain + Responses Position sense at 1 st toe Seizures Strength Rt UE (select): absent / diminished Parkinson s Strength Lt UE (select): absent / diminished Dementia or memory change Strength Rt LE (select): absent / diminished Strength Lt LE (select): absent / diminished Gait

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