|
Date of Exam
|
|
|
Patient Name
|
Date of Birth
|
|
Provider
|
Sex
|
|
|
|
|
Medicare Part B
|
Commercial
|
|
Type of Wellness Exam
|
Date of Last Exam
|
|
|
|
|
Vital signs
|
|
|
Height
|
Weight
|
|
Waist
|
Pulse Rate
|
|
Respirations
|
Temp
|
|
BMI
|
If BMI is abnormal: Follow up plan
|
|
BP
|
If BP is abnormal: Follow up plan
|
|
|
|
|
Subjective
|
|
|
Summary
|
|
|
|
|
|
Social History
|
Comments
|
|
Tobacco
|
Comments
|
|
Alcohol
|
Comments
|
|
Illegal Drugs
|
Comments
|
|
Marital Status
|
Comments
|
|
Employed
|
Comments
|
|
Hobbies
|
Comments
|
|
Caffeine Use
|
Exercise
|
|
Patient Diet
|
Hospice
|
|
Home Health
|
Other Physicians Seen
|
|
Assisted Living
|
Screenings, testings & referrals
|
|
Nursing Home
|
Significant findings/changes
|
|
Individual and family history
|
If yes, describe
|
|
Chronic problem list/riskfactor
|
Significant findings/changes
|
|
Educational materials were given
|
Significant findings/changes
|
|
Allergies
|
Significant findings/changes
|
|
Medication list
|
Significant findings/changes
|
|
Hospitalization list
|
|
|
|
|
|
Immunizations
|
Immunizations Needed
|
|
Immunizations Reviewed
|
|
|
|
|
|
Objective
|
Comments
|
|
General
|
Comments
|
|
HEENT
• • •
|
Comments
|
|
Neck
• • •
|
Comments
|
|
Chest
• • •
|
Comments
|
|
Lungs
• • •
|
Comments
|
|
Heart
|
Comments
|
|
Abdomen
• • •
|
Comments
|
|
Lymphatic
|
Comments
|
|
Integument:
|
Comments
|
|
Extremities
• • •
|
Comments
|
|
Neurologic
• • •
|
Comments
|
|
Psychiatric
• • •
|
If yes, results
|
|
Input from others
|
Notes and plan
|
|
CANS-MCI
|
|
|
|
PHQ-9
|
|
Depression Screening
|
Felt down depressed/hopeless
|
|
Expresses interest/pleasure
|
Notes and plan
|
|
Mood/affect
|
|
|
|
|
|
Functional Ability
|
Time to get up & walk
|
|
Exhibit a steady gait
|
Handle his/her own medications
|
|
Is the patient self reliant
|
Is the patient’s home safe
|
|
Patient handle his/her own money
|
Vision difficulties
|
|
Hearing difficulties
|
Notes and plan
|
|
Distance and reading eye charts
|
|
|
|
|
|
Advance Care Planning
|
If no, provide information
|
|
Advance care planning
|
If no, provide information
|
|
Living Will
|
If no, provide information
|
|
Advance Directive
|
|
|
|
|
|
Quality Measures
|
|
|
Breast Cancer Screening
|
Date and location of Mammogram
|
|
Colorectal Cancer Screening
• • •
|
Date and location of Colorectal Cancer Screening
|
|
Cervical Cancer Screening
• • •
|
Date and location of Cervical Cancer Screening
|
|
Fall Screening
|
Fall Screening Comments
|
|
HbA1c WNL?
|
HbA1c Value
|
|
Diabetic Eye Exam
• • •
|
Date and Name of Provider performing Eye Exam
|
|
Influenza Vaccination
|
Date and location where received
|
|
Diabetic Exam
|
Date and location where received
|
|
Other Relevant Findings
|
|
|
Notes and plan
|
|
|
|
|
|
BILLING
• • •
|
|
