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

ANNUAL WELLNESS VISIT Medical Form

Internist

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Published: April 27, 2022, 10:08 a.m.
Doctor: Dr. History Physical
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