|
|
|
|
MEDICARE PREVENTIVE PHYSCIAL EXAM
|
|
|
SOCIAL
|
Tabacco
|
|
Alcohol Abuse
|
Drug Use
|
|
Caffeine Intake
|
|
|
Family
|
|
|
Mother
• • •
|
Father
• • •
|
|
Recently Hospitalized for the past 30 days?
|
Name of the Hospital/ Date / Reason
|
|
Specialist Care Needed
• • •
|
|
|
Depression Screening
|
|
|
Depression for the patient 2 weeks?
|
|
|
Little Interest Doing Things?
|
|
|
Functional Ability/ Safety Screening
|
|
|
Does the patient’s need help with the phone etc.
|
Was the patient’s timed Up?
|
|
Does the patient’s need help with the phone etc.
|
Does the patient’s home have rugs in the hallway
|
|
Have you noticed any hearing difficulties?
|
Comments:
|
|
Cognitive Function
• • •
|
Vision Examination
|
|
EKG:
|
Advice/Referrals
|
|
Handout Reviewed & Discussed With Patient
|
Advanced Directives
|
|
SERVICE
|
Pneumococcal Vaccine, Influenza & Hep B
|
|
RECOMMENTATION
|
SCHEDULED
|
|
Mammogram
|
RECOMMENTATION
|
|
SCHEDULED
|
|
|
Pap & Pelvic Exam
|
RECOMMENTATION
|
|
SCHEDULED
|
|
|
Colorectal Cancer Screening
|
RECOMMENTATION
|
|
SCHEDULED
|
|
|
Diabetes self management training
|
RECOMMENTATION
|
|
SCHEDULED
|
|
|
Bone Mass Measurements
|
RECOMMENTATION
|
|
SCHEDULED
|
|
|
Glaucoma Screening
|
RECOMMENTATION
|
|
SCHEDULED
|
|
|
Cardiovascular screening blood test
|
RECOMMENTATION
|
|
SCHEDULED
|
|
|
Abdominal Aortic Aneurysm
|
RECOMMENTATION
|
|
SCHEDULED
|
|
|
HIV Screening
|
RECOMMENTATION
|
|
SCHEDULED
|
|
|
Smoking Cessation Counseling
|
RECOMMENTATION
|
|
SCHEDULED
|
|
|
Alcohol Cessation Counseling
|
RECOMMENTATION
|
|
SCHEDULED
|
|
