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Type of Wellness Exam
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Medicare Part B
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Eligibility Date
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Date of Last Exam
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Date of Last IPPE/AWV
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HPI
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Diet and Nutrition:
• • •
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Diet Comments:
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Fracture Risk:
• • •
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Fracture Risk Comments:
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Chronic problem list/riskfactor
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Significant findings/changes
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Allergies
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Significant findings/changes
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Medication list
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Significant findings/changes
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Hospitalization list
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Significant findings/changes
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Mental Status
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Orientation:
• • •
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CANS-MCI (Cognitrax Test Run)
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If yes, results
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Functional Ability
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Exhibit a steady gait
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Handle his/her own medications
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Is the patient self reliant
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Is the patient’s home safe
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Patient handle his/her own money
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Vision difficulties
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Hearing difficulties
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Notes and plan
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distance and reading eye charts
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Notes and plan
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Advance Care Planning
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Advance care planning
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Advance Directive
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If no, provide information
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Physical Exam:
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Medicare ACP
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Medicare AWV
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Obesity Screening and Counseling
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Plan of Care:
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Screening Recommendations:
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Vaccines:
• • •
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Screenings suggested:
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Pap test / Pelvic Exam Screening (ages 30-65, every 3-5 years depending on type of testing and individual; ages 65 and older, may not be recommended if historically normal)
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Bone Mass Measurement (DEXA scan for all women aged 65 and older; or younger than 65 with risk factors for fracture; repeat every 1-2 years if abnormal)
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Colorectal cancer Screening (colonoscopy every 10 years for adults aged 45-75; FIT yearly or Cologuard every 3 years; findings may indicate increased frequency) Colonoscopy
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Fecal Occult Blood
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Eye Exam Screening
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Cholesterol Screening: (every 5 years for all adults aged 40-75)
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Diabetes Screening (every 3 years for all adults at high risk)
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AWV Discussion
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What will I do? Chose one goal. (Ex: exercise)
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How Much (Ex: 20 mins)
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How Often (Ex: Mon, Wed, Fri)
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How confident are you that you will do this?
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Provider Summary / Dictation
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