|
Name of Consultant or Specialist
|
|
|
Name of Consultant or Specialist
|
Name of Consultant or Specialist
|
|
Name of Consultant or Specialist
|
Name of Consultant or Specialist
|
|
Hospital Visits
|
|
|
Hospital/ED in the last 12 months?
|
Reason
|
|
Have you been admitted into the hospital in the last 12 months?
|
Reason
|
|
Past Surgical History
|
|
|
Surgery type
|
Year L/R
|
|
Surgery type
|
Year L/R
|
|
Surgery type
|
Year L/R
|
|
Surgery type
|
Year L/R
|
|
Billing
|
Welcome to Medicare Visit
|
|
Initial Preventative Exam
|
Subsequent Preventative Exam
|
|
Family History
|
|
|
High Cholesterol
• • •
|
HTN
• • •
|
|
Heart Disease
• • •
|
Stroke
• • •
|
|
Diabetes
• • •
|
Dementia
• • •
|
|
Depression
• • •
|
Cancer
• • •
|
|
Other
• • •
|
Other
• • •
|
|
Past Medical History
|
|
|
High cholesterol
|
Arrhythmia (irregular hear beat)
|
|
Seizure disorder
|
Depression
|
|
Hypertension/high BP
|
Stroke
|
|
Multiple sclerosis
|
Anxiety disorder
|
|
Type 1 diabetes (insulin)
|
Type 2 diabetes
|
|
Specific bleeding disorder
|
Migraine
|
|
Congestive heart failure
|
Coronary artery disease
|
|
Obstructive sleep apnea
|
Asthma
|
|
Incontinence
|
Chronic kidney disease
|
|
Alcoholism
|
Drug abuse
|
|
COPD
|
Emphysema
|
|
Blood clots/DVT/PE
• • •
|
HIV/STD/TB/Lyme Disease
• • •
|
|
Cancer
|
Thyroid disease
|
|
Type
|
Type
|
|
Osteoarthritis
|
Other
|
|
Location
|
Other
|
|
Current Medication
|
|
|
Medication Reconciled
|
Not eligible for Med Reconciliation
|
|
Allergies:
|
|
|
Type
|
Reaction
|
|
Type
|
Reaction
|
|
Type
|
Reaction
|
|
Type
|
Reaction
|
|
Type
|
Reaction
|
|
Tobacco Screening
|
|
|
Tobacco Screening
• • •
|
Total years smoked
|
|
# / day ?
|
Date quit smoking
|
|
Tobacco Screen Negative
|
Tobacco Screen Positive
|
|
No Tobacco Screen
|
Patient counseled
|
|
Drug Misuse Screening:
|
|
|
Drug use:
|
Type of Drug:
|
|
Alcohol Screening:
|
|
|
Alcohol Screening:
• • •
|
# drinks/ week
|
|
Type of Alcohol
• • •
|
Have you consumed 4 or more drinks in one sitting this past year?
|
|
F/u plan?
|
Have you ever felt you should cut down on your drinking?
|
|
Have people annoyed you by criticizing your drinking?
|
Have you ever felt bad or guilty about your drinking?
|
|
Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
|
Face to face counseling, 15 minutes
|
|
Depression Screening:
|
|
|
Little interest or pleasure in doing things
• • •
|
|
|
Feeling down, depressed or hopeless
• • •
|
|
|
Trouble falling or staying asleep, or sleeping too much
• • •
|
|
|
Feeling tired or having little energy
• • •
|
|
|
Poor appetite or overeating
• • •
|
|
|
Feeling bad about yourself- or that you are a failure or have let yourself down
• • •
|
|
|
Trouble concentrating on things, such as reading the newspaper or watching television
• • •
|
|
|
Moving/ speaking slowly or being fidgety/ restless
• • •
|
|
|
SI/ HI
• • •
|
|
|
Total Score:
|
|
|
Depression Screen: Positive or Negative?
• • •
|
F/u plan if depression screen positive:
|
|
System Review (currently experiencing)
|
|
|
General
|
|
|
Fatigue
|
|
|
Weight loss:
|
Weight gain:
|
|
Amount/Time
|
Amount/Time
|
|
Fever
|
How high
|
|
Skin
|
|
|
Rash:
|
Raynaud's:
|
|
Hari Loss:
|
|
|
Special Senses
|
|
|
Hearing loss
|
Dry eyes
|
|
Eye pain with redness
|
Double vision
|
|
Vision loss (blindness)
|
Dry mouth (excessive)
|
|
Oral sores (recurrent)
|
Chronic Sinusitis
|
|
Nosebleeds (frequent)
|
|
|
Neck
|
|
|
Hoarseness (excessive)
|
Enlarged lymph node
|
|
Large thyroid
|
|
|
Respiratory
|
|
|
Cough (dry or productive)
|
Shortness of breath at rest
|
|
Shortness of breath active
|
Coughing up blood
|
|
Wheezing
|
Snoring
|
|
Sputum producing
|
|
|
Breast
|
|
|
Mass
|
Lump
|
|
Discharge
|
|
|
Cardiovascular
|
|
|
Chest pain (new and active)
|
Leg swelling (new or old)
|
|
History of heart murmur
|
|
|
Hematologic
|
|
|
Abnormal bleeding
|
|
|
Gastrointestinal
|
|
|
Nausea
|
Abdominal pain
|
|
Vomiting
|
Vomiting blood
|
|
Blood in stools
|
Black stools
|
|
Hemorrhoids
|
Heartburn (currently)
|
|
Difficulty swallowing
|
Diarrhea
|
|
Genitourinary
|
|
|
Blood in urine
|
Painful urination
|
|
Flank pain
|
Genital ulcer
|
|
Prostate issues
|
Foamy urine
|
|
Musculoskeletal
|
|
|
Joint pain
|
Joint swelling
|
|
Morning stiffness
|
Muscle pain
|
|
Lower back pain
|
Neck pain
|
|
Neurological and Psychiatric
|
|
|
Active insomnia
|
Localized loss of muscle
|
|
Numbness
|
Tingling
|
|
Difficulty with speech
|
Active anxiety
|
|
Active depression
|
|
|
Endocrine
|
|
|
Anorexia
|
Cold tolerance (excessive)
|
