|
Type of Wellness Exam
|
|
|
Medicare Part B
|
|
|
Eligibility Date
|
Date of Last Exam
|
|
Date of Last IPPE/AWV
|
Sex
|
|
Date
|
|
|
Vital signs
|
|
|
Height
|
Weight
|
|
Waist” or BMI
|
BP
|
|
Temp
|
Pulse Rate
|
|
Respirations
|
Special Accommodations Needed
|
|
Individual and family history
|
Significant findings/changes
|
|
Chronic problem list/riskfactor
|
Significant findings/changes
|
|
Educational materials were given
|
If yes, describe
|
|
Screenings, testings & referrals
|
|
|
Providers and suppliers
|
Significant findings/changes
|
|
Physicians
|
Home Health
|
|
Hospice
|
|
|
Allergies
|
Significant findings/changes
|
|
Medication list
|
Significant findings/changes
|
|
Hospitalization list
|
Significant findings/changes
|
|
Assessment Cognitive Impairment
|
|
|
General appearance
|
Mood/affect
|
|
Input from others
|
|
|
CANS-MCI
|
If yes, results
|
|
Notes and plan
|
|
|
Depression Screening
|
|
|
Expresses interest/pleasure
|
Felt down depressed/hopeless
|
|
Notes and plan
|
|
|
Functional Ability
|
|
|
Eexhibit a steady gait
|
Time to get up & walk
|
|
Is the patient self reliant
|
Handle his/her own medications
|
|
Patient handle his/her own money
|
Is the patient’s home safe
|
|
Hearing difficulties
|
Vision difficulties
|
|
distance and reading eye charts
|
Notes and plan
|
|
Advance Care Planning
|
|
|
Advance care planning
|
Advance Directive
|
|
If no, provide information
|
Notes and plan
|
|
Other Relevant Findings
|
Notes and plan
|
|
BILLING
• • •
|
|
