Demographics - SCAN Health Plan



MEMBER: ____________________________ PCP: ____________________________________

ANNUAL WELLNESS VISIT/INITIAL

GENDER: ____ AGE: ____ DOB: _________ DATE: __________________________________

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Reason for Visit:______________________________________________________________________________

Other concerns:_______________________________________________________________________________

Personal Medical History: Please indicate whether you have had any of the following medical problems with approximate date of illness or diagnosis:

|Condition |Year |Condition |Year |  |

|___Congestive Heart Failure |  | |___Cancer |  | |Other: |

|___Heart Attack |  | |___Diabetes |  | |  |

|___Stroke |  | |___Thyroid Problem |  | |  |

|___High Blood Pressure |  | |___COPD |  | |  |

|___Depression |  | |___High Cholesterol |  | |When was your last Tetanus shot? |

Medications: Please list current prescription and non-prescription medicines, vitamins, home remedies, herbs:

|Name |Date Last Filled |Name |Date Last Filled |

|  |  |  |  |

|  |  |  |  |

|  |  |  |  |

|  |  |   |  |

|  |  |   |  |

|  |  |   |  |

|  |  |   |  |

|  |  |   |  |

Allergies or reactions to medications:____________________________________________________________

Social History: Do you smoke? ο Yes ο No If so, how many packs a day _______ How many years ________

Do you consume alcoholic beverages? ο Yes ο No If so, how much a month ______________

Do you take recreational drugs? ο Yes ο No If so, frequency ___________________________

Other Medical Care: Please list other physicians or suppliers who provided medical care in the last 6 months:

|Name |Date |Condition |Name |Date |Condition |

| |  |  | |  |  |

| | | | | | |

| | | | | | |

| | | | | | |

Family History: Please indicate if any person, related by blood, had any of the following:

|Condition |Yes |

|HEENT: |MS: |

|RESP: |ENDO: |

|CARDIO: |NEURO: |

|GI: | |

|Physical Examination |Normal |Abnormal |Describe Findings |

|General |  |  |  |

|Skin |  |  |  |

|HEENT |  |  |  |

|Neck |  |  |  |

|Heart |  |  |  |

|Lungs |  |  |  |

|Abdomen |  |  |  |

|Musculoskeletal |  |  |  |

|Neurologic |  |  |  |

|Vascular |  |  |  |

|Lymphatic |  |  |  |

|Extremities |  |  |  |

|Rectal / GU |  |  |  |

Assessment Plan

_________________________________________________ ___________________________________________

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MEMBER: __________________________ PCP: ______________________________________

ANNUAL WELLNESS VISIT/INITIAL

GENDER: ____ AGE: ____ DOB: ________ DATE: _____________________________________

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Cognitive Assessment – Clock Drawing

MEMBER: __________________________ PCP: ______________________________________

ANNUAL WELLNESS VISIT/INITIAL

GENDER: ____ AGE: ____ DOB: ________ DATE: _____________________________________

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|Preventive Services |Plan/Goals/Barriers/Intervention/Follow-up |

|Flu Vaccine: ο Yes ο No |  |

|Date: | |

|Pneumonia Vaccine: ο Yes ο No | |

|Date: | |

|Mammogram: ο Yes ο No | |

|Date: | |

|Discuss chemoprevention with women at high risk for breast cancer:| |

|ο Yes ο No | |

|PAP: ο Yes ο No | |

|Date: | |

|Colorectal Screening: ο Yes ο No | |

|Date: | |

| | |

|  | |

|Social |Plan/Goals/Barriers/Intervention/Follow-up |

|Marital Status: ο Married ο Divorced |Plan/Goals/Barriers/Intervention/Follow-up |

|ο Single | |

|Counsel if at risk for STIs: ο Yes ο No | |

|At risk for syphilis: ο Yes ο No ο Screen | |

|At risk for HIV: ο Yes ο No ο Screen | |

|Counsel on tobacco use: ο Yes ο No | |

|Counsel on alcohol misuse: ο Yes ο No | |

|Transportation: ο Yes ο No | |

|Caregivers: ο Yes ο No | |

|Recreational Activities: ο Yes ο No | |

| | |

| | |

|Nutrition |Plan/Goals/Barriers/Intervention/Follow-up |

|BMI: |  |

|Hemoglobin: | |

|Serum Albumin: | |

|Recent Weight Change: ο Yes ο No | |

|Dietary counseling for weight loss or related chronic disease: | |

|ο Yes ο No | |

| | |

|  | |

MEMBER: _________________________ PCP: ______________________________________

ANNUAL WELLNESS VISIT/INITIAL

GENDER: ____ AGE: ____ DOB: ________ DATE: _____________________________________

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|Functional/Safety Assessment |Plan/Goals/Barriers/Intervention/Follow-up |

|Ability to Take Medication: ο Yes ο No |  |

|Feeding: ο Yes ο No | |

|Grooming: ο Yes ο No | |

|Toileting: ο Yes ο No | |

|Continence: Bladder: ο Yes ο No | |

|Bowel: ο Yes ο No | |

|Ambulation: ο Yes ο No | |

|Assistive Device: _____________________ | |

|Risk for Falls: ο Yes ο No | |

|Hearing Impairment: ο Yes ο No | |

| Uses Hearing Aid: ο L ο R ο Both | |

|  | |

| | |

|Psychological Assessment |Plan/Goals/Barriers/Intervention/Follow-up |

|PHQ-9 Score: _____________ |  |

|Recent Major Stress: ο Yes ο No | |

|Feeling Down: ο Yes ο No | |

|Sleep Disturbance: ο Yes ο No | |

|History of Depression: ο Yes ο No | |

|Advance Directive on File: ο Yes ο No | |

| | |

|  | |

|Cognitive Functioning |Plan/Goals/Barriers/Intervention/Follow-up |

|Clock Drawing Score: __________ |  |

|Oriented: ο Yes ο No | |

|Immediate Recall: ο Good ο Poor | |

|Delay Recall: ο Good ο Poor | |

|Confused: ο Mostly ο At times ο Not at All | |

|Memory Deficit: ο Yes ο No | |

|Inappropriate Behavior: ο Yes ο No | |

| | |

|  | |

|Case Management/Coordination |Plan/Goals/Barriers/Intervention/Follow-up |

|Risk of admission to hospital: ο Yes ο No |  |

|Risk of placement to SNF: ο Yes ο No | |

|Referral to Case Mgmt: ο Yes ο No | |

|Referral to Disease Mgmt: ο Yes ο No | |

| | |

| | |

Rendering Clinician Signature and Credential:_______________________________________________________

MEMBER: _________________________ PCP: __________________________________

ANNUAL WELLNESS VISIT/INITIAL

WRITTEN SCREENING SCHEDULE Date: __________________________________

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|Preventive Screening Checklist |Completed | |

| |Yes |No |Recommended |Scheduled |

|Flu vaccine in current season | | | | |

|Patients 60 yrs and older: Pneumococcal vaccine | | | | |

|Patients 50 yrs and older: ο Flex Sig in last 5 years | | | | |

|ο Colonoscopy in last 10 years | | | | |

|ο Fecal occult blood in current year | | | | |

| | | | | |

| | | | | |

|Patients 65 yrs and older: Glaucoma test by ophthalmologist or optometrist | | | | |

|Male Only | | | | |

|Lipid disorder screening | | | | |

|Abdominal aortic aneurysm screening if ever smoked | | | | |

|Men age 45-79: Use of aspirin to reduce risk of myocardial infarction (heart attack) | | | | |

|Female Only | | | | |

|Women 40 yrs or older: Mammogram in current or prior year | | | | |

|Women 65 yrs or older: Bone density test every 2 years if normal | | | | |

|Women with bone fracture in last 12 months: Bone density test OR on medication to treat or | | | | |

|prevent osteoporosis | | | | |

|Lipid disorder screening if at risk for coronary heart disease | | | | |

|Women age 55-79: Use of aspirin to reduce risk of ischemic stroke | | | | |

|Member with Cardiovascular Disease | | | | |

|Patients with cardiovascular conditions in current or prior year. | | | | |

|---Lab test for LDL-C in current year | | | | |

|---Most current LDL-C value in current year is ................
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