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Explained to patient check ON
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New or secondary Wellness Exam?
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Date of Last IPPE/AWV
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Medicare Eligibility Date
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Date of Last Exam
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VS Ht Wt BMI done check ON
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Check this YES for review done:
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Is the family history complete?
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Updated family history: if any changes
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Reviewed chronic problems
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Any new problems added? write in
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Reviewed medication list w/pt or MAR
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Any new med changes?
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Reviewed Allergies?
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Any new allergies reported?
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Any recent hospitalizations?
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Hospitalizations this year & why
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Is the patient seeing other MDs?
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MDs the patient has seen, why
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Is the patient on Home Health?
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Home Health Company:
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Is the patient on hospice?
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Hospice company:
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CHECKLIST FOR PATIENT WELLNESS
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Did you review checklist?
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Assess Cog Impairment check ON
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Did you assess cognition?
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If you received any input from others describe:
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Patient handle his/her own money
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Was MMSE performed?
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MMSE Score (if tested)
• • •
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Depression Screening check ON
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Patient's general appearence/mood/affect:
• • •
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Reviewed depression risk factors
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Did pt fill out the PHQ-9?
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PHQ-9 score
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Functional Ability
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Did u review functional ability?
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The pt can perform IADLs:
• • •
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IADL comments:
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The pt can perform these ADLs
• • •
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ADL comments:
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Can pt handle own medications?
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Self-medication comments:
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Does pt have a steady gait?
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Time to get up & walk in secs
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Does pt use walker, WC or cane?
• • •
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Is the patient’s home safe?
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Home safety comments:
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Vision difficulties
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Does pt wear glasses?
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Any hearing difficulties?
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Does pt use hearing aid?
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What is patients race?
• • •
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PREVENTATIVE CARE
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Received pneumococcal vaccine?
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Comments:
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up to date flu vaccination?
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Comments:
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Pt get Shingles vaccine?
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Comments:
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Is pt approp for colonoscopy?
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Comments:
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pt approp for glaucoma screen?
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Comments:
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Approp for bone mass screen?
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Comments:
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Approp for mammogram?
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Comments:
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Approp for any other screen?
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Comments:
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ADVANCED CARE PLANNING:
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Does pt have Advance Directive?
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Did you discuss advanced care planning?
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Comments:
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Does patient have a DNR?
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Comments:
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Recommendations include:
• • •
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Comments:
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Additional Comments? type here:
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TYPE IN other Referrals & recommendations
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EDUCATIONAL MATERIALS
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Educational materials were given
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TYPE IN any educational materials given
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