MEDICARE PERSONALIZED PREVENTION PLAN SERVICES ENCOUNTER FORM – Page 1 of 3

Patient’s name: ______Date of Birth: ______Medical Record #: ______

Medicare’s B eligibility date: ______Date of Exam: ______Date of last exam: ______

MEDICAL/SOCIAL HISTORY

Injury or illness / Date / Hospitalized?

Medications, supplements and Vitamins:

______

______

Social history notes (including diet and physical activities): ______

______

In the past year, have you had more than 5 (for men) and 4 (for women) alcoholic drinks in a single day more than twice? ( ) Y ( ) N

Family History Notes:

______

______

______

DEPRESSION SCREEN

1.  Over the past two weeks, have you felt down, depressed or hopeless ( ) Yes ( ) No

2.  Over the past two weeks, have you felt little interest or pleasure in doing things? ( ) Yes ( ) No

FUNCTIONAL ABILITY/SAFETY SCREEN

1.  Was the patient’s timed Up & go test unsteady or longer than 30 seconds ( ) Yes ( ) No

2.  Do you need help with phone/transportation/shopping/meals/housework/laundry/medications/money mgmt? ( ) Yes ( ) No

3.  Does your home have rugs in the hallway, lack grab bars in bathroom, lack stair handrails, havepoor lighting? ( ) Yes ( ) No

4.  Have you noticed any hearing difficulties? ( ) Yes ( ) No

Hearing Evaluation: ______

PHYSICAL EXAMINATION

Height: ______Weight: ______Blood Pressure: ______BMI: ______

Visual Acuity: L ______R ______

ELECTROCARDIOGRAM

Referral or result: ______

EVALUATIONS/REFERRALS BASED ON HISTORY, EXAM AND SCREENING: ______

______

Past Surgeries ______

Past Illnesses______

OTHER PHYSICIANS (Name & Specialty): ______

______

Patient Signature & Date: Physician Signature:

PERSONALIZED PREVENTION PLAN SERVICES (MINI-MENTAL SCREENING) Page 2 of 3 Medical Record #: ______

Patient ______Dr. Signature ______Date: ______

Maximum / Score
5 / Orientation
·  What is the current year Correct? ( )
·  What is the current season Correct? ( )
·  What is the current month Correct? ( )
·  What day of the week is today Correct? ( )
·  What is today’s date Correct? ( )
5 / ·  Which town is this clinic in? Raleigh ( )
·  What country are you in currently? USA ( )
·  What street are you at currently? Six Forks/Spring Forest ( )
·  Which facility are you in currently? Dr. Chatterjee’s ( )
·  Which State are we in? North Caroline ( )
3 / Registration
·  Name 3 objects: Ball, Car, Man. Take 1 seconds to say each. Then ask the patient all three. Give 1 point for each correct answer. Repeat until the patient has learnt all three. Count trials and record:
Trial: ______
5 / Attention and Calculation
·  Spell WORLD backwards
3 / Recall
·  Ask for the 3 objects (Ball, Car, man). Give 1 point for each correct answer
2 / Language
·  Show patient a Pen and ask to name the object
·  Show patient a watch and ask to name the object
1 / ·  Ask the patient to repeat the phrase “No ifs, and’s or buts.”
3 / ·  Ask the patient to take a paper, fold it in half and put it on the table (1 point for each step)
1 / ·  Give the patient a block to say “CLOSE YOUR EYES” and ask them to read and follow
1 / ·  Write a sentence
1 / ·  Copy the design shown

Total

Assess level of consciousness along a continuum

Alert Drowsy Stupor Coma

PERSONALIZED PREVENTION PLAN SERVICES ENCOUNTER FORM – Page 3 of 3 Medical Record #: ______

COUNSELING and REFERRAL OF OTHER PREVENTIVE SERVICES

Services / Limitations (Applicable Only for Medicare) / Recommendations / Scheduled
Vaccines
• Pneumococcal
• Influenza
• Hepatitis B (if medium/high risk) / No deductible/no co-pay
Medium/high-risk factors:
• End-stage renal disease
• Patients with hemophilia who received Factor VIII/IX concentrates
• Clients of institutions for the mentally retarded
• Persons who live in the same house as a carrier of Hepatitis B virus
• Homosexual men
• Abusers of illicit injectable drugs
Mammogram
Pap and Pelvic exams
Prostate cancer screening [Last done]
·  Digital Rectal Exam (DRE)
·  Prostate specific antigen (PSA)
Colorectal cancer screening
• Fecal occult blood test
• Flexible sigmoidoscopy
• Screening colonoscopy
• Barium enema / Exempt from Part B deductible
Diabetes and self-management
training / Requires referral by treating physician for patient
With diabetes or renal disease
Bone bass measurements / Requires diagnosis related to osteoporosis or
Estrogen deficiency
Glaucoma testing
Medical nutrition therapy for
Diabetes or renal disease / Requires referral by treating physician for patient
With diabetes or renal disease
Cardiovascular screening blood tests
• Total cholesterol
• High-density lipoproteins
• Triglycerides / Order as a panel if possible
Diabetes screening tests
• Fasting blood sugar (FBS) or glucose
tolerance test (GTT) / Patient must be diagnosed with one of the following:
. Hypertension
. Dyslipidemia
. Obesity (BMI >=30 kg/m2)
. Previous ID of elevated impaired FBS or GTT
.. or any two of the following:
. Overweight (BMI >=25 but <30)
. Family history of diabetes
. Age 65 years or older
. History of gestational diabetes or birth to baby
weighing more than 9 pounds
Abdominal aortic aneurysm screening
·  Sonogram / Patient must be referred through IPPE and not have
had a screening for abdominal aortic aneurysm
before under Medicare. Limited to patients who
meet one of the following criteria:
• Men who are 65-75 years old and have smoked
more than 100 cigarettes in their lifetime
• Anyone with a family history of abdominal aortic aneurysm
• Anyone recommended for screening by the U.S. Preventive Services Task Force
Eye check (Last eye check: )

Physician’s signature: ______Date: ______