Demographics - SCAN Health Plan
MEMBER: ____________________________ PCP: ____________________________________
ANNUAL WELLNESS VISIT/INITIAL
GENDER: ____ AGE: ____ DOB: _________ DATE: __________________________________
Page 1 of 6
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
_________________________________________________ ___________________________________________
_________________________________________________ ___________________________________________
_________________________________________________ ___________________________________________
_________________________________________________ ___________________________________________
_________________________________________________ ___________________________________________
_________________________________________________ ___________________________________________
_________________________________________________ ___________________________________________
_________________________________________________ ___________________________________________
_________________________________________________ ___________________________________________
MEMBER: __________________________ PCP: ______________________________________
ANNUAL WELLNESS VISIT/INITIAL
GENDER: ____ AGE: ____ DOB: ________ DATE: _____________________________________
Page 4 of 6
Cognitive Assessment – Clock Drawing
MEMBER: __________________________ PCP: ______________________________________
ANNUAL WELLNESS VISIT/INITIAL
GENDER: ____ AGE: ____ DOB: ________ DATE: _____________________________________
Page 5 of 6
|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: _____________________________________
Page 6 of 6
|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: __________________________________
Page 1 of 2
|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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