Enrollee Health Assessment Form



|Member ID: | |Suffix: | |Group #: | |

|Date of Birth: | |Age: | |Sex: |M F |

|Provider name: | |Provider name: | |Date: | |

| |Signature | |Printed | | |

|Fax completed form to: 425-918-6738 (local) or 855-332-4527 (toll free) |Billing Codes: | G0438 – Initial Visit |

|Note: A blank form is available online at wa/provider, Library> Forms> Care | |G0439 – Subsequent Visit |

|Management. | | |

|Vital Signs |

|Height: | |Weight: | |BMI: | |Prior weight and date: | |

|Smoker: |Yes No |# of packs: | |Alcohol drinks/week: | |

|Blood pressure: | |/ | Sitting Lying Standing | | |

|Respiratory rate: | |MA Initials:* | |* Required if medical assistant (MA) completes vitals |

|Pre-visit Prescription Information (Check all boxes that apply and add comments as applicable.) |

|Date Last Filled:|Currently |Prescription Name: |Dosage: |Chronic |Questions for today: |

| |Taking? | | |Medication? |Main diagnosis? Change dose? Starting? Stopping? |

| | | | | |Side effects? Allergies? |

| |No | | |No | |

| |Yes | | |Yes | |

| | | | | | |

| | | | | | |

| |No | | |No | |

| |Yes | | |Yes | |

| | | | | | |

| | | | | | |

| |No | | |No | |

|Pre-visit Review/Prior History |

|Code/Description: |Yes|No |What Conditions? |

| DME | | | |

| Ostomy | | | |

| Known allergies (Drug and any other) | | | |

|Within the last 12 months, has member had any of the |Yes|No |What Conditions? |

|following: | | | |

| ER visit | | | |

| Hospital admission | | | |

| Visit with other specialists | | | |

|Screening and Testing |

| |

| |Status: |Describe Abnormal Findings: | |Status: |Describe Abnormal Findings: |

| | No distress | | | | |

|Ears | Normal (Anatomy) | |Cardiovascular | Normal | |

| | Normal (Hearing) | | | | |

|Eyes | Normal (Anatomy) | |Abdomen | Normal (Appearance) | |

| | Normal (Vision) | | | Normal (Manual) | |

|Nose | Normal | |Extremities | Normal | |

|Throat | Normal | | | | |

|Head | Normal | |Neurological | Normal | |

|Neck | Normal | |Other | Normal | |

|Diagnoses Review |

|If diagnosis is positive, please fill out the following sections: Conditions, Treat/Meds, Teaching, and Testing. |

|Code/Description: |

|Controlled |Uncontrolled |Neurological Manifestations |

| Dx 250.60 DM, Type II | Dx 250.62 DM, Type II | |

| Dx 250.50 DM, Type II | Dx 250.52 DM, Type II | |

| Dx 250.40 DM, Type II | Dx 250.42 DM, Type II | |

| Dx 250.70 DM, Type II | Dx 250.72 DM, Type II | |

| Dx 250.80 DM, Type II | Dx 250.82 DM, Type II | |

|Controlled |Uncontrolled | | |

| Dx 250.00 DM, Type II | Dx 250.02 DM, Type II |

|Controlled |Uncontrolled | | |

| Dx 250.10 DM, Type II | Dx 250.12 DM, Type II | |

|Ischemic Heart Problems | | |

| Dx 414.00 Coronary Artery Disease | | |

| Dx 428.0 Congestive Heart Failure, unsp. | | |

| Dx 427.31 Atrial Fibrilation | | |

| Dx 440.23 Atherosclerosis of Extremities | | |

|w/Ulceration_________________(site) | | |

| Dx 746.4 Cong. Aortic Valve Insufficiency | | |

|Asthma | | |

| Dx 493.90 Asthma, NOS | | |

| Dx 496 COPD | | |

| Dx 486 Pneumonia | | |

| Dx 780.57 Sleep Apnea, unsp. | | |

| Dx 416.8 Pulmonary Hypertension, NOS |

| Dx 162.9 Mal. Neoplasm, Bronchus/Lung | | |

|Arthritis, Major Types | | |

| Dx 714.0 Rheumatoid Arthritis | | |

| Dx 710.0 Sytemic Lupus Erythematosus |

| Dx 733.00 Osteoporosis, unspec | | |

|Ulcer and Pressure Ulcer | | |

| Dx 707.10 Ulcer of lower limb, unspec | | |

| Dx 707.2_____ (Specify Stage I-IV) |

| Dx 172.9 Malig Melanoma of Skin, site unsp. | | |

|Stroke/Paralysis | | |

| Dx 342.90 Hemiplegia, Unspecified | | |

| Dx 343.9 Cerebral Palsy, NOS | | |

| Dx 345.90 Epilepsy, NOS w/o Intractable Epilepsy |

| Dx 336.9 Myelopathy, NOS |

| Dx 758.0 Down's Syndrome |

| Dx 331.4 Obstructive Hydrocephalus | | |

|Substance Problems | | |

| Dx 292.0 Drug Withdrawal Syndrome | | |

| Dx 296.30 Major Depressive Disorder, unspec | | |

| Dx 296.90 Affective Psychosis, NOS | | |

| Dx 301.83 Borderline Personality Disorder | | |

| Dx 307.51 Bulimia Nervosa | | |

| Dx 299.00 Autistic Disorder, Active |

|Endocrine | | |

| Dx 242.90 Hyperthyroidism, NOS | | |

| Dx 272.4 Hyperlipidemia, NOS | | |

| Dx 263.0 Malnutrition of Moderate Degree |

|Blood Cell and Blood Marrow Problems | | |

| Dx 282.61 Hb-SS Disease w/o Crisis | | |

| Dx 289.81 Primary Hypercoagulable State |

| Dx 205.00 Acute Myeloid Leukemia |

| Dx 193 Malig Neoplasm, Thyroid Gland | | |

|Liver | | |

| Dx 571.1 Acute Alcoholic Hepatitis | | |

| Dx 577.1 Chronic Pancreatitis | | |

| Dx 555.9 Crohn's disease, NOS |

| Dx 585.__ Chronic Kidney Disease (Stages I-V) I |

|Cancer/Ostomies/HIV/AIDS |

|(Do not code old cancers that have been treated and are in remission) |

Dx 174.9 Malig Neoplasm, Breast (female), unsp Dx 189.0 Malig Neoplasm, Kidney NOS Dx 197.7 Sec Mal Neoplasm Liver Dx 153.9 Malig Neoplasm, Colon, unsp Dx 183.0 Malig Neoplasm, Ovary Dx V44.1 Gastrostomy status Dx V44.3 Colostomy status Dx 042 HIV/AIDS Dx V08 HIV + (no symptoms are present)

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