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