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Date of Exam
|
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Patient Name
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Date of Birth
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Provider
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Sex
|
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|
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Medicare Part B
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Commercial
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Type of Wellness Exam
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Date of Last Exam
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Vital signs
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|
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Height
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Weight
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Waist
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Pulse Rate
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Respirations
|
Temp
|
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BMI
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If BMI is abnormal: Follow up plan
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BP
|
If BP is abnormal: Follow up plan
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Subjective
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Summary
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|
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Social History
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|
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Tobacco
|
Comments
|
|
Alcohol
|
Comments
|
|
Illegal Drugs
|
Comments
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|
Marital Status
|
Comments
|
|
Employed
|
Comments
|
|
Hobbies
|
Comments
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|
Caffeine Use
|
Comments
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|
Patient Diet
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Exercise
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Home Health
|
Hospice
|
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Assisted Living
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Other Physicians Seen
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Nursing Home
|
Significant findings/changes
|
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Individual and family history
|
If yes, describe
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Chronic problem list/riskfactor
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Significant findings/changes
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|
Educational materials were given
|
|
|
Allergies
|
Significant findings/changes
|
|
Medication list
|
Significant findings/changes
|
|
Hospitalization list
|
Significant findings/changes
|
|
|
|
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Immunizations
|
|
|
Immunizations Reviewed
|
Immunizations Needed
|
|
|
|
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Objective
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General
|
Comments
|
|
HEENT
• • •
|
Comments
|
|
Neck
• • •
|
Comments
|
|
Chest
• • •
|
Comments
|
|
Lungs
• • •
|
Comments
|
|
Heart
|
Comments
|
|
Abdomen
• • •
|
Comments
|
|
Lymphatic
|
Comments
|
|
Integument:
|
Comments
|
|
Extremities
• • •
|
Comments
|
|
Neurologic
• • •
|
Comments
|
|
Psychiatric
• • •
|
Comments
|
|
Input from others
|
|
|
CANS-MCI
|
If yes, results
|
|
Notes and plan
|
|
|
|
|
|
Depression Screening
|
PHQ-9
|
|
Expresses interest/pleasure
|
Felt down depressed/hopeless
|
|
Mood/affect
|
Notes and plan
|
|
|
|
|
Functional Ability
|
|
|
Exhibit 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
|
If no, provide information
|
|
Living Will
|
If no, provide information
|
|
Advance Directive
|
If no, provide information
|
|
|
|
|
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
• • •
|
|
