DearPatient,

ThankyouforschedulingyourWelcometoMedicareVisitwithus.

Thisvisitwill:

  • introduceyoutothepreventiveservicescoveredbyMedicare
  • screenfordepression
  • assessyourfunctionalability
  • assesshomesafetymeasures
  • provideyouwithawrittenchecklist outliningrecommendedpreventivemeasures.

Youarenotrequiredtocompletethe“WelcometoMedicare”physicaltoparticipateintheMedicareprogram.

Pleasecomepreparedforyourappointment:

  • Fillouttheenclosedforms and return to us at your visit or by email to ouremailaddress.com or via our web portal
  • Ifyouareunabletocompletetheformsinadvance,pleasecometoouroffice45to60minutesaheadofyourappointmenttimetocompletethem.TheyarerequiredbyMedicareforthisvisit.
  • BringyourMedicareInsurancecardwithyousothatwemayverifyyoureligibilityforthisvisit.
  • Bepreparedwithalistofanyconcernsyouwouldlikethephysiciantoaddress.
  • Bring all current medications or a list of them

There is no charge for the Welcome to Medicare visit.
However, yourphysicianmayneedtotreatotheracuteandchronichealthissuesinadditiontoperformingyourwellnessexam(thesameappointment).

ChargesfortheseseparateserviceswillbefiledtoMedicareandmayresultinoutofpocketexpenseforyoudependingonyourcoverageforillnessvisits.

Sincerely,

Thephysiciansandstaffof(yourpractice)Telephonenumber

Yoursignaturebelowindicatesthatyouhavereadandunderstandthatyouwillbefinanciallyresponsiblefortheportionofyourphysicalnotcoveredbyyourinsurance.

SignatureDate

ProvidersandSuppliersofYourMedicalCare:

Pleaselistallprovidersandsuppliersofyour medicalcaresuchas primarycarephysicians, specialty physicians,chiropractors,pharmacies,herbalists andtherapists.

PrimaryCare Physician(s) / Specialty
OtherPhysicians / Specialty,Chiropractor, Pharmacies,Therapist
,

CurrentMedications:

Please includeprescriptions,over-thecounter medications,vitamins andsupplements.

Medicationname / Dose / Route / Frequency

MedicationAllergies:

Medication / Reaction

DAILYASPIRINUSE

Haveyoudiscussedtakingadailyaspirinwithyourdoctor?

Yes

No

YourHistory:Pleasechecktheappropriate boxforthe conditionsastheyapplyto you:

MedicalHistory

Condition / yes / no / Comments / Condition / yes / no / Comments / Condition / Yes / No / comments
Allergies / Depression / HeartAttack
(Myocardial infarction)
Anemia / Diabetes / Nerve/muscle disease
Anxiety / Emphysema / Osteoporosis
Arthritis / Reflux, Heartburn (GERD) / Seizures
Asthma / Glaucoma / Sicklecellanemia
Blood transfusion / Heart murmur / Stroke
Cancer / HIV/AIDS / Substanceabuse
Cataracts / High Blood
Pressure (Hypertension) / Thyroiddisease
Heart
Failure (CHF) / Kidneydisease / Tuberculosis
Clotting disorder / Meningitis / Ulcers
Chronic
obstructive lung disease (COPD)
OtherMedicalHistory:

SurgicalHistory:Female

Surgery / Yes / No / Comments / Surgery / Yes / No / Comments / Surgery / Yes / No / Comments
Appendectomy / Cosmetic surgery / Joint replacement
Brainsurgery / C-Section / Small intestine surgery
BreastSurgery / Eye surgery / Spinesurgery
GallBladder Surgery (Cholecystectomy) / Fracture surgery / Tubal Ligation
Colon surgery / Hernia
repair / Heart Valve
Replacement

SurgicalHistory:Male

Surgery / Yes / No / Comments / Surgery / Yes / No / Comments / Surgery / Yes / No / Comments
Appendectomy / Cosmetic surgery / Prostate surgery
Brain surgery / Eye surgery / Small
intestine surgery
Heart Bypass / Fracture surgery / Spine surgery
GallBladder Surgery (Cholecystectomy) / Hernia repair / Heart Valve Replacement
Colon surgery / Joint replacement / Vasectomy

Othersurgicalhistory:

FamilyHistory: Please checkthe appropriate boxoftheconditions thatapplyto yourbloodrelatives:

Father / Mother / Sister / Brother / Aunt AuAuDaughter AuAuntDaughter Daughter / Uncle / Daughter / Son
Alive
Deceased
Alcoholabuse
Arthritis
Asthma
Birth Defects
Cancer
ChronicObstructive
lung disease (COPD)
Depression
Diabetes
DrugAbuse
Early Death
Hearing Loss
HeartDisease
HighCholesterol
Hypertension
Kidney Disease
LearningDisability
Mentalillness
Mental Retardation
Miscarriages
Stroke
Visionloss

comments:

SocialHistory:

AlcoholUse

YesNo

IfYes:numberofdrinksperweek

If Yes:type(s)ofalcoholicbeverages

SexuallyActive

YesNoNotcurrently

IfYes:Circleappropriateresponses

Partner(s):MaleFemale

IfYes:Birthcontrol/Protectionused

DrugUse

YesNo

IfYes:numberoftimesusedperweek

IfYes: listtype(s)ofrecreationaldrugsused

Tobacco Use

YesNo

Completeappropriateresponsesbelow:

CurrentEveryDaySmoker?Number of packsper dayNumberofYears

CurrentSmoker?(not daily)Number ofpacksperweekNumberofYears

FormerSmoker?Quitdate

PassiveSmoker?

Areyouready toQuit?YesNo

SmokelessTobaccoUse

YesNo

Completeappropriateresponsesbelow:

FormerUser?

NeverUsed

Quitdate

Areyouready toQuit?YesN