PDF Please attach supporting chart notes to this template

Patient Name: Date of birth: Member ID: PCP name: PCP group:

Annual Wellness Visit Medicare Advantage

G0438 or G0439 + S0250

Date of wellness visit:

Please attach supporting chart notes to this template

Current list of all conditions, including conditions being treated by a specialist

No data available for member conditions

Height: Weight: BMI*:

Physical Exam

Blood Pressure: Heart rate: Temperature:

Enrolled in Silver & Fit

Please complete a relevant exam and assessment/plan of all chronic conditions listed above. Attach supporting chart notes as appropriate.

*See BMI chart on last page.

Support Services

030156 (09-2014)

Page 1 of 9

Patient Name:

Current list of all medications, including medications prescribed by a specialist

If patient is taking angiotensin-converting-enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), digoxin, diuretics, or anticonvulsants, please schedule a follow-up visit and labs to monitor these medications. Please review medication list for high-risk medications and consider alternatives (see ProvLink/Pharmacy High Risk Medication Formulary Guide and the Geriatric Prescribing Pearls Pathways to Treat). Please include supplements, including calcium and vitamins.

No data available for member conditions

Procedures and labs performed in 2015-2016

No data available for member conditions

Current list of patient's providers and suppliers (e.g., specialists and DME)

No data available for member conditions

Support Services

030156 (09-2014)

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Patient Name:

Medical/Family/Social History

Past personal illnesses, injuries, operations

Date Hospitalized? Medications,

Yes

No

supplements, vitamins:

Yes No Drug allergies:

(Physician may substitute own template for PFSH and ROS) Notes:

Yes Yes Yes Yes

No No No No

Tobacco use: Alcohol use: Illicit drug use:

How much/long? Quit/when?

See EHR

Yes No Yes No Yes No

Alcoholism

Cancer

Review of Systems (check all that apply)

Kidney disease Seizures

Hypertension

Arthritis

Diabetes

Liver disease

Stroke

Respiratory disease Heart disease

Thyroid disease Obesity

(Physician may substitute own template for PFSH and ROS) Notes:

Hearing Loss Screen

1. Does the patient have trouble hearing the television or radio when others do not?

2. Does the patient have to strain or struggle to hear/understand conversations? If yes, consider audiology consultation.

Yes No Yes No

Depression Screen

1. Over the past two weeks, how often has the patient felt down, depressed, or hopeless?

Not at all (0)

Several days (1)

More than half

the days (2)

Nearly every day

(3)

2. Over the past two weeks, how often has the patient felt little interest or pleasure in doing things?

Not at all (0) Several days (1)

More than half

the days (2)

Nearly every day

(3)

A negative response to both questions is considered a negative result for depression. If the patient has a positive response to either

question, administer the PHQ-9 available at ncbi.nlm.pmc/articles/PMC1495268/#app1. See ProvLink/Pharmacy: Pathway to

Treat Depression.

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Patient Name:

Fall Prevention

1. Is the patient taking vitamin D? If yes, for preventive or treatment purposes?

2. Does patient have a history of falling within the past 12 months? If yes, consider a Timed Up and Go Test to assess mobility.

3. Does the patient require an ambulatory aid when walking? 4. Does the patient experience hypotension? 5. Does the patient have gait/balance or walking problems in the past 12 months or lower extremity

weakness? 6. Does patient have risk factors at home (e.g., loose rugs, inadequate grab rails, poor lighting)?

If patient has experienced a fall within the last year, consider referral to physical therapy.

Yes, under treatment Yes, for prevention No Yes No

Yes Yes Yes

No No No

Yes No

Physical Health

1. In the past 4 weeks, has the patient had any problems with regular daily activity as a result of their physical health?

2. Does the patient have a regular exercise program? If no, is the patient physically active in ways other than a formal exercise program?

3. Would the patient like to discuss participation in physical fitness program? Advise patient to start, increase or maintain level of exercise or physical activity. Discuss appropriate exercises or refer to a fitness program: .

4. Does the patient have any problems with Activities of Daily Living, such as bathing, dressing, eating, transferring (e.g., getting in and out of chairs), using the toilet, or walking?

5. How would you rate your overall physical health?

6. If less than "Excellent" ? Are there specific areas of your physical health that you would like to focus on to help you rate that higher? Note and/or address those areas.

Yes No

Yes Yes Yes

No No No

No, ADL done independently with no problems Yes, problems with ADL

If yes, which activities: Bathing Dressing Dressing Eating Transferring Using the toilet Walking OR ADL done with caregiver assist Excellent Good Fair Poor

Yes No

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Patient Name:

Pain Screen

1. On a scale of 1-5, how would the patient rate their overall pain? 1=no pain, 5=unbearable pain

1

2

3

4

5

2. Would the patient like to discuss pain management?

Yes No

If yes, please develop appropriate pain management plan. See ProvLink/Pharmacy: Pathway to Treat Persistent, Non-Malignant Pain.

Bladder Control

1. In the past six months, has the patient experienced urinary leakage, also sometimes called bladder

Yes No

control?

2. Would the patient like to discuss treatment options?

Yes No

If yes, please develop appropriate treatment plan. See ProvLink/Pharmacy: Pathway to Treat Urinary Incontinence.

If no, remind member that this is a medical condition that can be discussed at any time, should the patient develop any

concerns.

Cognitive Function

1. In the past 4 weeks, has the patient had any problems with regular daily activities as a result of any emotional problems?

Yes No

If yes or patient is 70 years of age or older, perform Mini-CogTM

1. Word Recall: 1 point for each word spontaneously recalled without cueing

0

1

2

3

2. Clock Draw: Normal clock = 2 points. A normal clock has all numbers placed in the correct sequence and

0

approximately correct position (e.g., 12, 3, 6 and 9 are in anchor positions) with no missing or duplicate

2

numbers. Hands are pointing to the 11 and 2 (11:10). Hand length is not scored. Inability or refusal to

draw a clock (abnormal) = 0 points.

3. Total score: Word Recall score + Clock Draw score.

0

1

2

3

4

5

A cut point of ................
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