Transcription
Name: DOB: / /MR: FIN:ANNUAL WELLNESS VISIT - HEALTH RISK ASSESSMENT(HRA)Dear ,Your Appointment for the Welcome to Medicare Visit OR Annual Wellness Visit is scheduledon at .There is NO CO-PAY for this visit, so it is free for you!The goal of this visit is to provide time for you to discuss with our health care team, areas of your healththat may put you at risk for problems and to help you and your provider better understand what screeningsyou should get in the future.At your wellness visit, we will take a complete health history and provide several other services: Screenings to detect depression, risk for falling and other problems, A limited physical exam to check your blood pressure, weight, vision and other things dependingon your age, gender and level of activity, A screening schedule for appropriate preventive services will be developed Risk factors and treatment options will be reviewed and recommendedThis is NOT a “Problem Visit and WILL NOT include treatment or management of problems.So that your provider has all necessary information, please complete ALL of the enclosed forms andbring them with you to your visit.If you arrive at the office without these forms, your visit may need to be rescheduled.Please make sure to be on time and call with more than 24 hours’ notice if you cannot make yourappointment.We look forward to seeing you soon!Page 1LCB:4/18
Name: DOB: / /MR: FIN:ANNUAL WELLNESS VISIT - HEALTH RISK ASSESSMENT(HRA)Please complete the entire questionnaire as thoroughly as possible so that your provider has a completeand up to date history. This confidential history will be part of your permanent medical recordPlease list all providers and suppliers of your medical care such as primary care physicians, specialtyphysicians, chiropractors, pharmacies, herbalists and therapists.Primary Care Physician(s)SpecialtyOther Providers:SpecialtyPage 2LCB:4/18
Name: DOB: / /MR: FIN:ANNUAL WELLNESS VISIT - HEALTH RISK ASSESSMENT(HRA)Current Medications:Please include prescriptions, over-the counter medications, Vitamins, Herbs, and SupplementsMedication nameDoseFrequencyDAILY ASPIRIN USEHave you discussed taking a daily aspirin with your doctor?Route Yes No I don’t know I already take a daily aspirinMedication Allergies:MedicationReactionPage 3LCB:4/18
Name: DOB: / /MR: FIN:ANNUAL WELLNESS VISIT - HEALTH RISK ASSESSMENT(HRA)Medical History: Please check the appropriate box for the conditions as they apply to you.NoHeart hmaGlaucomaSickle cellanemiaBloodtransfusionHeart igh BloodPressure(Hypertension)Thyroid diseaseKidney mentsYesConditionOther Medical History:Page 4LCB:4/18
Name: DOB: / /MR: FIN:ANNUAL WELLNESS VISIT - HEALTH RISK ASSESSMENT(HRA)Surgical History: FemaleCommentsAppendectomyCosmeticsurgeryBrain surgeryC-SectionBreast SurgeryEyesurgerySpine surgeryGall l LigationColon surgeryHerniarepairHeart rgerySurgical History: MaleAppendectomyCosmeticsurgeryBrain surgeryEye surgeryHeart surgerySpinesurgeryGall BladderSurgery(Cholecystectomy)HerniarepairHeart ValveReplacementColon ryNoCommentsYesSurgeryNoCommentsYesSurgeryOther Surgical History:Page 5LCB:4/18
Name: DOB: / /MR: FIN:ANNUAL WELLNESS VISIT - HEALTH RISK ASSESSMENT(HRA)Vision lossStrokeMiscarriagesMental RetardationMental illnessLearning DisabilityKidney DiseaseHypertensionHigh CholesterolHeart DiseaseHearing LossEarly DeathDrug AbuseDiabetesCancerBirth DefectsAsthmaArthritisAlcohol abuseDeceasedAliveRelationChronic Obstructivelung disease (COPD)DepressionFamily History: Please check the appropriate box of the conditions that apply to your blood al HistoryAlcohol Use: How many times in the past year have you had4 or more drinks in a day?Tobacco Use: Do you use any type of tobacco products? None 1-2 3-4 5 I don’t drink alcohol Yes NoIf Yes: Complete the information below: Cigarettes Chew Cigars Pipe Snuff Smokeless Tobacco (Vape) Current Every Day Smoker? Number of packs per dayNumber of Years Current Smoker? (not daily) Number of packs per week Number of Years Former Smoker?Quit date Passive Smoker (2nd hand/inhalation of smoke)?Are you interested in quitting tobacco? Yes No I don’t use tobaccoAre you interested in receiving help for any other type of substance Yesabuse?Page 6 No I don’t use other substancesLCB:4/18
Name: DOB: / /MR: FIN:ANNUAL WELLNESS VISIT - HEALTH RISK ASSESSMENT(HRA)PHYSICAL ACTIVITYHow many days a week do you usually exercise? None 1-2 3-4 5 I don’t knowOn days when you exercise, for how long do you usuallyexercise?How intense is your typical exercise? (Check one) 0-30 30 min to1 hour More than 1 hour I don’t know I am currently not exercising Light (like stretching or slow walking) Moderate (like brisk walking) Heavy (like jogging or swimming) Very heavy (like fast running or stair climbing) I am currently not exercisingNUTRITIONHow many servings of fruits and vegetables do you havein a day None 1-2 3-4 5 I don’t knowHow many servings of meat, fish or other proteins do youhave in a day?How many servings of fiber or whole grains do you have ina day? None 1-2 3-4 5 I don’t know None 1-2 3-4 5 I don’t knowHow many servings of fried or high-fats foods do you havein a day? None 1-2 3-4 5 I don’t knowHow many servings of sugar sweetened drinks do youhave in a day? None 1-2 3-4 5 I don’t knowORAL HEALTHHow is the health of your mouth and teeth?Do you visit the dentist regularly? Excellent Good Fair Poor Yes No I don’t know I don’t knowMOTOR VEHICLE SAFETYDo you always fasten your seat belt when you are in the car? Yes No I do not driveDo you ever drive after drinking, or ride with a driver who has been drinking? Yes No I do not drive Yes No SometimesSUN EXPOSUREDo you protect yourself from the sun when you are outdoors?Page 7LCB:4/18
Name: DOB: / /MR: FIN:ANNUAL WELLNESS VISIT - HEALTH RISK ASSESSMENT(HRA)DEPRESSION SCREENING (PHQ9)Circle your answer’sPage 8LCB:4/18
Name: DOB: / /MR: FIN:ANNUAL WELLNESS VISIT - HEALTH RISK ASSESSMENT(HRA)GENERAL WELL-BEINGIn general, would you say your health is? Excellent Very good GoodDo you take all your medications asprescribed?In the last six months, how many times wereyou admitted to the hospital? Yes No 0In the last six months, how many times haveyou been to the emergency room? 0SOCIAL/EMOTIONAL SUPPORTHow often do you get the social and emotionalsupport you need? AlwaysSTRESS/ANGERHow often is stress/anger a problem for you?How well do you handle the stress/anger in your life?PAIN/FATIGUEHow often do you feel unusually tired?Do you have pain that interferes with performingdesired activities? Fair Poor 1-2 Sometimes AlmostNever 3-4 5 I don’t takemedication I don’t know 1-2 3-4 I don’t know Usually Sometimes 5 Rarely Never Never, rarely Sometimes I’m usually ableto cope effectively At times I haveproblems coping Never, rarely Sometimes Often Always Never, rarely Sometimes Often Always Often Always I often have problemscopingSLEEPHow many hours of sleep do you usually get? 0-3 4-6 7-10 10 I don’t knowDo you snore or has anyone told you that you snore? YesIn the past 7 days, how often have you felt sleepyduring the daytime? Often Sometimes Almost never Never I don’t knowPage 9 No I don’t knowLCB:4/18
Name: DOB: / /MR: FIN:ANNUAL WELLNESS VISIT - HEALTH RISK ASSESSMENT(HRA)FUNCTIONAL ABILITY ASSESSMENTInstrumental activities of daily livingWhich of the following can you do on your own?Activities of daily livingWhich of the following can you do on without help? Shop for groceries Use the telephone Housework Handlefinances Drive/use public transportation Make meals Take medications None Bath Walk Dress Eat Transfer in/out of chair, etc Use the restroom None Yes No I don’t knowMany experience leakage of urine, also calledurinary incontinence. In the past 6 months, have youexperience leakage of urine?Ambulation StatusHow long can you walk or move around? 0-5 5-15 15-30 More than 1 hour I don’t knowDo you feel unsteady when standing or walking?Which of these assistive devices do you use?Do you feel dizzy when you get up from a bed orchair?Are you afraid to leave the house alone due todizziness or imbalance problems?Fall Risk AssessmentHave you fallen in the past year? Yes No Sometimes I don’t know Cane Walker Wheelchair Crutches Other None Yes No Sometimes I don’t knowHow many times have you fallen in the past year?Do you worry about falling? 1-2 3-4 5 I don’t know I did not fall Yes No Sometimes Yes No Sometimes I don’t know Yes No I don’t knowPage 10LCB:4/18
Name: DOB: / /MR: FIN:ANNUAL WELLNESS VISIT - HEALTH RISK ASSESSMENT(HRA)HEARING SCREENINGDo you have a problem with hearing? Yes No I don’t knowDo you use hearing aids or other devices to help you hear? Yes No I don’t knowDo you have a problem hearing the telephone? Yes No I don’t knowDo you have trouble hearing the television or radio Yes No I don’t knowDo people complain that you turn the TV volume up too high? Yes No I don’t knowDo many people you talk to seem to mumble (or not speak clearly)? Yes No I don’t knowDo you find yourself asking people to repeat themselves? Yes No I don’t knowDo you have trouble hearing in a noisy background? Yes No I don’t knowVISION SCREENINGDo you have problems with your vision? Yes No I don’t knowDo you wear contact lenses or eyeglasses? Yes No SometimesHOME SAFETYWhat is your living situation Alone With my spouse or other family with a friend orroommate In nursing home or assisted living facility/home I don’t have a place to live OtherDoes your home have rugs in the hallways? Yes No I don’t knowDoes your home have grab bars in the bathroom? Yes No I don’t knowIs there any clutter in your walking space at home? Yes No I don’t knowDoes your home have functioning smoke alarms? Yes No I don’t knowDoes your home have handrails on stairs and steps? Yes No I don’t knowMEMORY LOSSHave you experienced any memory issues or problems with thinking?Do family members report that you have difficulty remembering things?END OF LIFE PLANNINGDo you have an Advance Directive, Living Will or Power of Attorney forHealth Care (POA), in the case that an injury or illness causes you to beunable to make healthcare decisions?Would you like further information regarding Advance Directives?HRA Reviewed by: Yes Yes No No I don’t know I don’t know Yes No I don’t know Yes No I already have oneOFFICIAL USE ONLYClinician Name(Print):Date:Clinician Signature:Page 11LCB:4/18
Your Appointment for the Welcome to Medicare Visit OR Annual Wellness Visit is scheduled . Please complete the entire questionnaire as thoroughly as possible so that your provider has a complete . HEALTH RISK ASSESSMENT(HRA) Page 10 LCB:4/18
