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Patient Name
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Patient DOB
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Patient PCP
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Best Phone Number to reach pt
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Date of last Office Visit
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Patient Insurance Plan
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CPC+ Patient?
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ACO Patient?
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Reviewed medication list w/pt or MAR
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Reviewed Allergies?
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Is the patient seeing other MDs?
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Name(s) of Specialist(s)
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Chronic Conditions
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Epilepsy
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Anemia
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HTN
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Arthritis
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HLD
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Cancer
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MS
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CHF
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Obesity
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CKD
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COPD
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Depression
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Schizophrenia or Bi-Polar
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Diabetes
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Stroke
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Other Chronic Conditions, please list
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Risk Score
• • •
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Preventive Care
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Current Tobacco User?
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If a current tobacco user, how much and often?
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Psycho-Social Needs
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Does pt have a steady gait?
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Has pt fallen or had a fall injury in last 12 months?
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Does pt use walker, WC or cane?
• • •
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Comments:
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Date of next Care Management Visit
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