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MEDICARE PREVENTIVE PHYSCIAL EXAM
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SOCIAL
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Tobacco
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ETOH
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Drug
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Caffeine
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Family
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Deceased
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HTN
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CV Disease
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CVA
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Kidney
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Obesity
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Liver
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CA
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Other:
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Other Providers Of Care:
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Type of Care
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Other:
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Depression Screening
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Has the patient felt down, depressed,or helpless
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Has the patient felt little interest?
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Functional Ability/ Safety Screening
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Was the patient’s timed Up?
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Does the patient’s need help with the phone etc.
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Does the patient’s home have rugs in the hallway
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Have you noticed any hearing difficulties?
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Comments:
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Cognitive Function
• • •
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Vision Examination
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EKG:
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Advice/Referrals
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Handout Reviewed & Discussed With Patient
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Advanced Directives
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SERVICE
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Pneumococcal Vaccine, Influenza & Hep B
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RECOMMENTATION
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SCHEDULED
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Mammogram
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RECOMMENTATION
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SCHEDULED
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Pap & Pelvic Exam
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RECOMMENTATION
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SCHEDULED
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Colorectal Cancer Screening
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RECOMMENTATION
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SCHEDULED
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Diabetes self management training
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RECOMMENTATION
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SCHEDULED
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Bone Mass Measurements
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RECOMMENTATION
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SCHEDULED
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Glaucoma Screening
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RECOMMENTATION
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SCHEDULED
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Cardiovascular screening blood test
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RECOMMENTATION
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SCHEDULED
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Abdominal Aortic Aneurysm
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RECOMMENTATION
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SCHEDULED
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HIV Screening
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RECOMMENTATION
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SCHEDULED
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Smoking Cessation Counseling
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RECOMMENTATION
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SCHEDULED
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Alcohol Cessation Counseling
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RECOMMENTATION
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SCHEDULED
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