Power & Brown Family Medicine
Dayton Family MedicineAnnual Wellness VisitName__________________________Who is eligible for the Annual Wellness Visit (AWV)?New members, during the first 12 months after becoming eligible for Medicare, are entitled to a Welcome to Medicare visit. Thereafter, Medicare covers an AWV for all patients every 12 months.What is the Annual Wellness Visit (AWV)?Annual Wellness Visit (AWV) is a preventative wellness visit and/or discussion about your current health status is not a “routine physical exam”. During this visit the provider begins to form a plan of care for you for the year.What should I know/do before my appointment?You will come to your appointment 15 minutes prior to seeing the provider so that our staff can review your packet to ensure it is complete. You will need to bring to the appointment 1. List of medications and supplements 2. Complete list of current providers and supplier 3. Immunization record 4. Family health history.Is Lab work part of the AWV?Lab work review is not included in the AWV, but may be determined/ordered at your AWV.What is the purpose of the AWV? What are some of the things done at the AWV?The provider reviews information and many aspects of your health in order to develop and individualized plan of care for you.i.e. Review past medical history and surgeries, family history, height/weight, blood pressure and medication will be reviewed, as well as screenings including those for safety, falls, memory, depression, activities of daily living, and hearing. Referrals and follow up with specialists, preventative testing, and immunizations you may be due for will be reviewed.What happens at the end of the AWV?You will be given a Plan of Care at the end of your appointment, which will provide recommendations for your care for the year.Providers will decide which labs will be ordered, determine follow up needed for and new or chronic condition/issues, as well as schedule future appointment(s) for the physical exam and review.What happens if one of the prevention screening tests is abnormal or need further evaluation/discussion/treatment?If any screenings/testing are abnormal your provider will develop a plan for further evaluation either at our office or with a referring provider.What happens if I want to talk about a new problem or a chronic condition at my AWV?Per Medicare, the AWV is a wellness visit to develop a plan of care for you for the year. A separate appointment will be needed for a new problem (i.e. knee pain, sore throat), a chronic condition (i.e. diabetes, high cholesterol), or the physical exam (breast, pelvic, prostate).-On a rare occasion if there is a concern/problem that takes priority and needs to be immediately addressed (blood pressure too high), your provider may choose to cancel the AWV and pay a co-pay or fee determined by your insurance for today’s visit.-Infrequently, if there is a small concern addressed by your provider at your AWV (i.e. sore throat) your co-pay/insurance fee would apply to the visit also.Provider InitialsToday’s DatePage 1Health Risk AssessmentName:DOB:Date:1. Can you get places out of walking distance without10. During the past 4 weeks, was someone available tohelp? help you if you needed and wanted help?*For example, can you travel alone by bus, taxi or*For example, if you felt very nervous, lonely or blue,Drive your own car?got sick and had to stay in bed, needed someone toYes talk to, needed help with daily chores, or needed helpNojust taking care of yourself.2. Can you shop for groceries or clothes Yes, as much as I wantedwithout help?Yes, quite a bitYesYes, someNoYes, a little 3. Can you prepare your own meals?11. How often in the past 4 weeks, have you had troubleYes eating well?NoNever4. Can you do your own house work without help?SeldomYesSometimesNoOften5. Can you handle your own moneyAlwayswithout help?12. How often in the past 4 weeks, have you been Yesbothered by your teeth or dentures?NoNever6. Do you need help eating, bathing, dressing orSeldomgetting around your home?Sometimes YesOften NoAlways 7. Are you having difficulties driving your car?13. How often in the past 4 weeks, have you hadNoproblems using the telephone?SometimesNever Yes, oftenSeldomNot applicable, I don’t use a carSometimes 8. Have you been given any information to help youOften Keep track of your medications? AlwaysYes 14. Have you been given information to help you Noidentify hazards in your house that might hurt you?9. How often do you have trouble taking medicinesYes the way you have been told to take them?NoI don’t have to take medicine15. Do you always fasten your seat belt whenI always take them as prescribedyou are in a car?Sometimes I take them as prescribed Yes, usuallyI seldom take them as prescribedYes, sometimesNo Page 2Health Risk AssessmentName:DOB:Date:16. Have you had sex in the past 12 months?22. How confident are you that you can controlYesand manage most of your health problems?NoVery confident17. Have you ever had a sexually transmitted disease?Somewhat confidentYesNot very confidentNoI do not have any health problems18. During the past 4 weeks, how much bodily pain have 23. Over the past 2 weeks, have you experiencedyou generally had?having little interest or pleasure in doing things?No painYesVery mild painNoMild pain24. Over the past 2 weeks, have you beenModerate painfeeling down, depressed or hopeless?Severe painYes19. During the past 4 weeks, what was the hardest physicalNoactivity you could do for at least 2 minutes?25. Are you a smoker?Very heavyNoHeavyYes, and I might quit?ModerateYes, but I’m not ready to quitLight26. Did you have a drink containing alcoholVery lightin the past year?20. During the past 4 weeks, how would you rate your Yesgeneral health?NoExcellent27. Are you afraid of falling?Very goodYesGoodNoFair28. Have you fallen two (2) or more times in the past year?PoorYes21. How have things been going for you in the past 4Noweeks?29. Were you injured in any falls in the past year?Very well-could hardly be betterYesPretty goodNoGood and bad are about equalPretty badVery bad-could hardly be worsePage 3Name:DOB:Date:Alcohol ScreeningDid you have a drink containing alcohol in the past year?YesNo If “Yes”: How often did you have a drink containing alcohol in the past year? Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week If “Yes”: How many drinks did you have on a typical day when you were drinking in the past year? 1 or 2 drinks 3 or 4 drinks 5 or 6 drinks 7 to 9 drinks 10 or more drinks If “Yes”: How often did you have 6 or more drinks on one occasion in the past year? Never Less than monthly Monthly Weekly Daily or almost dailyLiving Will Do you have a Living Will?YesNo Do you have a Medical Power of Attorney?YesNo Does our office have a copy?YesNo*If there has been changes to your Living Will and/or Power of Attorney please describe the changes: Page 4Name:DOB:Date:Tobacco ControlAre you a Current smoker Former smoker nonsmoker current every day smoker current some day smoker Smoker current status unknown unknown if ever smoked light tobacco smoker heavy tobacco smoker Uses tobacco in other formsAdditional Findings: Tobacco User Chain smoker Chews fine cut tobacco Chews loose leaf tobacco Chews plug tobacco Chews tobacco Chews twist tobacco Heavy cigarette smoker (20-39 cigs/day) Light cigarette smoker (1-9 cigs/day) Moderate cigarette smoker (10-19 cigs/day) Pipe smoker Rolls own cigarettes Snuff user Trivial cigarette smoker (less than one cigarette/day) User of moist powdered tobacco Very heavy cigarette smoker (40+cigs/day)Additional Findings: Tobacco Non-User Aggressive non-smoker Current non-smoker Current non-smoker, but past smoking history unknown Does not use powdered tobacco Ex-cigar smoker Ex-cigarette smoker Ex-cigarette smoker amount unknown Ex-heavy cigarette smoker (20-30/day) Ex-light cigarette smoker (1-9/day) Ex-moderate cigarette smoker (10-19/day) Ex-pipe smoker Ex-trivial cigarette smoker Ex-user of moist powdered tobacco Ex-very heavy cigarette smoker (40+/day) Intolerant ex-smoker Intolerant non-smoker Never used moist powdered tobacco Non-smoker for medical reasons Non-smoker for personal reasons Non-smoker for religious reasons Tolerant ex-smoker Tolerant non-smoker Page 5PATIENT HEALTH QUESTIONAIRE (PHQ2/PHQ-9)Name:DOB:Date:Over the last 2 weeks, how often have you been bothered by any of the following problems?(use a check mark to indicate your answer)Not at allSeveral DaysMore than half the dayNearly every dayTrouble falling or staying asleep, or sleeping too much0123Little interest or pleasure in doing things0123If you answered YES to either of the questions above please answer questions 3-9Feeling down, depressed, or hopeless0123Feeling tired of having little energy0123Poor appetite or overeating0123Feeling bad about yourself, or that you are a failure or have let yourself or your family down0123Trouble concentrating on things, such as reading the newspaper or watching television0123Moving or speaking so slowly that other people could have noticed or the opposite, being so fidgety or restless that you have been moving around a lot more than usual0123Thoughts that you would be better off dead, or of hurting yourself0123Add columns(Healthcare professional: For interpretation of TOTAL please refer to accompanying scoring card).TOTALS:If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?Not difficult at allSomewhat difficultVery difficultExtremely difficultCopyright ? 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ? is a trademark of Pfizer Inc.A2663B 10-04-2005Page 6Name:DOB:Date:List of current doctors:Provider Name:Specialty Phone #1.___________________________________________________________________________________________________2.___________________________________________________________________________________________________3.___________________________________________________________________________________________________4.___________________________________________________________________________________________________5.___________________________________________________________________________________________________6.___________________________________________________________________________________________________7.___________________________________________________________________________________________________8.___________________________________________________________________________________________________9.___________________________________________________________________________________________________10.__________________________________________________________________________________________________List of current medications: (PLEASE BRING MEDICATION BOTTLES WITH YOU!)MedicationMGDirections1.___________________________________________________________________________________________________2.___________________________________________________________________________________________________3.___________________________________________________________________________________________________4.___________________________________________________________________________________________________5.___________________________________________________________________________________________________6.___________________________________________________________________________________________________7.___________________________________________________________________________________________________8.___________________________________________________________________________________________________9.___________________________________________________________________________________________________10.__________________________________________________________________________________________________MiscellaneousHave any of your close relatives had any health changes?YesNoIf yes, explain:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you had any preventative tests done in the last year (for example labs, mammograms, bone density, x-ray, colonoscopy)? TESTLOCATIONDATETESTDATEColonoscopyProstateMammogramPap SmearBone DensityBlood TestEye ExamMiscHave you had any immunizations in the last year? Yes No IMMUNIZATIONDATEIMMUNIZATIONDATEFluShinglesPneumoniaMiscDtapPage 7Dayton Family MedicineJared Dayton D.O.6840 East Brown RD Suite 101Mesa, AZ 85207480-285-2150/ FX 480-285-2151Thank you for entrusting us with your healthcare needs. You are scheduled for an “Annual Wellness Visit and/or Yearly Physical Exam” this is to inform you what is and what is not covered by your health plan.Covered Items:Review/Update medical and family history.Review risk factors for safety, alcohol, depression etc.Vitals; height, weight, BMI, blood pressure, temperatureReview of medicationsReview of current providersReview of immunizationsPersonalized health advice and appropriate referrals to health educationIf appropriate; Mammogram and bone density orders, Cardiology and/or GI referral for further testing.If you have other items that need to be addressed we may be able to address these at this appointment if time allows. Be aware that this is not covered as part of the “Annual Wellness Visit” and you may receive a bill for a co-pay or office evaluation.Non-Covered Items (partial list);Adjustment or refill of medicationsReview of labs or imaging studiesDiscussions about health conditions i.e. Diabetes, recent injuries, cholesterol problemsBy signing this form I understand and agree to the terms of this appointment.Patient NameDatePatient SignatureRelationship to patientPage 8 ................
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