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Type of living condition:
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What is your primary Language?
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GENERAL HEALTH PERCEPTION
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1. How would you rate your over-all health?
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My health is important to me
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MEDICAL/FAMILY/SOCIAL HISTORY
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Medical History -->
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*Tap Here (Medical History)
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* - Past Medical History:
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Tap Here (Past MH)
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- Past MH Comments:
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Tap Here (Past MH Comments)
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* - Past Surgical History:
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Tap Here (Past SH)
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- Past SHx Comments:
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Tap Here (Past SH Comments)
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- Childhood Immunization:
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Tap Here (Childhood Immunizations)
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- Childhood Imm. Comments:
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Tap Here (CI Comments)
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Family History -->
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*Tap Here (Family History)
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- Father (Alive/Deceased)
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Tap Here (Alive)
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- Father's Medical History:
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Tap Here (Father's MH)
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- Father MH Comments:
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Tap Here (Father MH Comments)
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- Mother (Alive/Deceased)
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Tap Here (Alive)
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- Mother's Medical History:
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Tap Here (Mother's MH)
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- Mother MH Comments:
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Tap Here (Mother MH Comments)
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- Brother(s) Total:
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Tap Here (Brother's Total)
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- Sister(s) Total:
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Tap Here (Sister's Total)
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- Sibling Medical History:
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Tap Here (Sibling MH)
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- Sibling MH Comments:
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Tap Here (Sibling MH Comments)
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- Son(s) Total:
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Tap Here (Son's Total)
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- Daughter(s) Total:
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Tap Here (Daughter's Total)
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- Children Medical History:
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Tap Here (Children MH)
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- Children MH Comments:
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Tap Here (Children MH Comments)
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Social History -->
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*Social History
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- Martial Status:
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Tap Here (Marital Status)
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- Occupation:
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Tap Here (Occupation)
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* - Sexual History:
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Tap Here (Sexual Hx)
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- Sexual History Comments:
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Tap Here (Sexual Hist. Comments)
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- Living Arrangement:
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Tap Here (Living Arrangements)
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- Living Arrangement Comments:
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Tap Here (Living Arrangement Comments)
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- Alcohol:
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*Tap Here (Alcohol)
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- Other Substances:
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*Tap Here (Other substances)
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- Smoking:
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*Tap Here (smoking)
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List of current providers and suppliers:
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Preferred DME Supplier
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Preferred pharmacy
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Other Medical Provider 1
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Provider 1 Name
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Other Medical Provider 2
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Provider 2 Name
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Other Medical Provider 3
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Provider 3 Name
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Other Medical Provider 4
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Provider 4 Name
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Other Medical Provider 5
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Other Medical Provider 5
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COGNITIVE ASSESSMENT
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Depression:
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In the past 2 weeks, how often have you felt down, depressed, or hopeless?
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In the past 2 weeks, how often have you felt little interest or pleasure in doing things?
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Have your feelings caused you distress to get along with family or friends?
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Anxiety:
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In the past 2 weeks, how often have you felt nervous, anxious, or on edge?
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In the past 2 weeks, how often were you not able to stop worrying or control your worrying?
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Tap here (Anxiety comments):
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High Stress:
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How often is stress a problem for you in handling such things as: –Your health?
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Tap here (health stressor comments):
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How often is stress a problem for you in handling such things as: –Your finances?
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Tap here (financial stressor comments):
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How often is stress a problem for you in handling such things as: –Your family?
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Tap here (family stressor comments):
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How often is stress a problem for you in handling such things as: –Your social relationships?
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Tap here (social relationships stressor comments):
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How often is stress a problem for you in handling such things as: –Your work?
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Tap here (work stressor comments):
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Social/Emotional support:
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How often do you get the social and emotional support you need:
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During the past 4 weeks, has your physical and emotional health limited your social activities with family, friends, neighbors?
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Over the past 2 weeks, how often have you been bothered by any of the ff. problems?
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Trouble sleeping or staying asleep or sleeping too much
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Feeling tired or having little energy:
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Poor appetitte or overeating:
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Feeling bad about yourself
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Trouble concentrating on things such ass watching TV:
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Moving or speaking so slowly that other people noticed or the opposite – being so fidgety?
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Have you felt restless that you have been moving around a lot more than usual?
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Thoughts that you would be better off dead or hurting yourself in some way?
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RISK ASSESSMENT
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Risk Assessment (Nutrition)
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How many servings of the following would you typically eat in the last 7 days day?
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a. Fruits and Vegetables (1 serving = 1 piece of fruit, ½ cup fruits or vegetables)
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b. High Fiber (1 serving = 1 cup cold cereal, ½ cup cooked cereal, 1 slice bread)
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c. High fat foods(1 serving = Bacon, French fries, chips, doughnut, fried chicken/fish):
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d. Sugar Sweetened Beverages (1 serving = 1 can or 12 oz. cup of soda or juice)
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Risk Assessment (Exercise)
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What was the hardest physical activity you could do for at least 2 minutes?
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Do you do moderate to strenuous exercise for about 20 minutes for 3 or more day/ week?
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Risk Assessment (Medication Compliance)
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How often do you have trouble taking medicines the way you have been told to take them?
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Risk Assessment (Vices)
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How often do you use any kind of tobacco, including cigarettes, cigars, pipe, snuff?
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Are you interested in quitting?
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Do you use any recreational drugs?
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If yes, what type?
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Do you drink alcohol?
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During the past 4 weeks, how many drinks of alcoholic beverages did you have?
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FUNCTIONAL ABILITIES AND ACTIVITIES OF DAILY LIVING ASSESSMENT:
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Instrumental Activities of Daily Living In the past 7 days, did you need help from others to take care of things such as laundry
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How many hours of sleep do you get per day?
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Do you snore or has anyone told you that you snore?
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In the past 7 days, how often have you felt sleepy during the daytime?
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Do you need help with any of the following activities?
• • •
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Do you need help with any of the following activities?
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During the past 4 weeks, was someone available to help if you needed and wanted help?
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LEVEL OF SAFETY ASSESSMENT
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Do you feel safe at home?
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Have you had any episode of vertigo?
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Do you need assistance to move around at home?
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Have you had a fall two or more times in the past year?
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Have you been given information to help you with the hazards at home that might hurt you?
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Have you been given information to help you in keeping track of your medications?
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ADVANCED CARE PLANNING
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Do you have a Medical Power of Attorney? (In the event you are unable to medically decide)
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Do you have a living will/advance directive? (Documents that makes your health care wishes known)
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Is a copy of your advance directive on file at your doctor’s office?
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Prepare to discuss your Advanced Care Plan with your provider
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Do you want to take part in making decisions about your care and treatment?
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Do you always want to know the truth about your condition?
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Do you want to consider your finances when treatment decisions are being made?
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New Would you want palliative care on relief of suffering and control of symptoms?
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Do you want to be an organ donor?
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Would you prefer at-home hospice care over being in a hospital?
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How do you feel about using life-sustaining measures in the face of a terminal illness?
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Mechanical breathing
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CPR
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Feeding tube
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Kidney dialysis
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Intensive care
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Chemo or radiation therapy
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I wish to have my life prolonged as long as possible within the limits of generally accepted health care standards.
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I do not wish to prolong my life if: (check all that apply)
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Advanced Care Plan Comments:
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PREVENTIVE SERVICES PLAN
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Mammogram Service Plan
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Pap and Pelvic Exam Plan
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Prostate Cancer Screening Plan
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Colorectal Cancer Screening Plan
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Diabetes Self- Management Plan
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Bone Mass Measurements Plan
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Glaucoma Screening Plan
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Medical Nutrition Therapy Plan
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Cardiovascular Screening Plan
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Diabetes Screening Plan
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Abdominal Aortic Aneurysm Screening Plan
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HIV Screening Plan
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Smoking Cessation Counseling Plan
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Subsequent AWV Plan
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INTERVENTIONS BASED ON RISK FACTORS
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Mobility
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Mobility Plan
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Other Functional Limitations
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Other Functional Limitations Plan
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Cognitive Limitations
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Cognitive Limitations Plan
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Psych. Evaluation
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Pych. Evaluation Plan
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Nutritional Status
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Diet
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Nutrition/Diet Plan
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Safety Issues in Home
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Safety Plan
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SCREENING COMMENTS
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