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Type of Wellness Exam
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Medicare Part B
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Eligibility Date
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Date of Last Exam
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Date of Last IPPE/AWV
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Individual and family history
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Special Accommodations Needed
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Chronic problem list/riskfactor
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Significant findings/changes
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Educational materials were given
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Significant findings/changes
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Screenings, testings & referrals
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If yes, describe
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Providers and suppliers
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Significant findings/changes
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Physicians
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Home Health
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Hospice
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Allergies
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Significant findings/changes
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Medication list
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Significant findings/changes
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Hospitalization list
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Significant findings/changes
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Assessment Cognitive Impairment
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General appearance
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Mood/affect
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Input from others
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CANS-MCI (Cognitrax Test Run)
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Notes and plan
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If yes, results
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Depression Screening
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Expresses interest/pleasure
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Felt down depressed/hopeless
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Notes and plan
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Functional Ability
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Eexhibit a steady gait
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Handle his/her own medications
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Is the patient self reliant
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Is the patient’s home safe
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Patient handle his/her own money
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Vision difficulties
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Hearing difficulties
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Notes and plan
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distance and reading eye charts
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Notes and plan
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Advance Care Planning
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Advance care planning
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Advance Directive
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If no, provide information
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Other Relevant Findings
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Notes and plan
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Results and Follow-Up
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Things That May Be Affecting Your Health
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Alcohol
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Lack of Physical Activity
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Depression
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Loneliness
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Diabetes
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Motor Vehicle Safety
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Difficulty with Daily Activities
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Oral Health
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Drug Use
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Pain
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Falls
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Sexual Health
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Food Choices
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Stress
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Hearing Loss
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Tiredness
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Home Safety
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Tobacco Use
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Medicines
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Weight
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Other
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Other
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BILLING
• • •
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Covered Preventive Screenings & Services
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Screening services needed
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Annual Wellness Visit Action Plan
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What will I do? Chose one goal. (Ex: exercise)
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How Much (Ex: 20 mins)
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How Often (Ex: Mon, Wed, Fri)
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How confident are you that you will do this?
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Provider Summary / Dictation
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