MEDICARE PREVENTIVE HEALTH SCREENING Date ______

MEDICARE PREVENTIVE HEALTH SCREENING Date ______

Name ______Birth date______

Address ______

Home Phone # ______Cell Phone # ______

Who should we contact in case of your medical emergency?

Name______Phone ______

Do you have a Living Will or Health Care Power of Attorney? □ Yes □ No

If yes - please be sure we have a copy on file. If not - please ask your doctor for information.

Depression Screen:

No Yes -Over the past 2 weeks, have you felt down, depressed, or hopeless?

NoYes - Over the past 2 weeks, have you felt little interest or pleasure in doing things?

Do you have any trouble with: □ Hearing □Seeing □ Walking □ Memory

In the last 12 months how many times have you fallen down? ______

Does your home have: □ Loose Rugs □Poor Lighting □ Multiple Levels □ Exposed Cords
□ Bath grab bars □ Stair Handrails □ Pets □ Smoke and CO Detectors

Medical Devices Used:

□ Glasses / □ Cane / □ Oxygen / □ Pacemaker / □ Insulin
□ Hearing Aid / □ Walker / □ CPAP / □ Defibrillator / □ Colostomy
□ Dentures / □ Wheelchair / □ Nebulizer / □ Heart Valve / □ Catheter

How much help do you need with the following tasks?

Activity / Independent / Need Some Help / Unable to Do
Using the Telephone / □ / □ / □
Travelling to Places Away from Home / □ / □ / □
Grocery or Clothes Shopping / □ / □ / □
Preparing Meals / □ / □ / □
Doing Housework or Handyman Work / □ / □ / □
Doing Laundry / □ / □ / □
Taking Medications / □ / □ / □
Managing Money / □ / □ / □
Total Score:______= / 2 x Sum ___ / + Sum ___ / + 0

______

Weight ______Height ______BP ______P _____ O2 _____Get Up and Go Time: _____

UA Glucose _____ if > 125 then HbA1c ____ if Welcome to Medicare: EKG  Hgb_____

Vision: □ Glasses □ Contacts □ None / Hearing:
Right / Left / Both
Acuity: / 20/ / 20/ / 20/
Color: Pass Fail / 1000hz / 2000hz / 4000hz / 500hz
R 25
40
L 25
40
SERVICE / FREQUENCY / LAST DONE / NEXT DUE / DONE TODAY
Wellness Visit / Annual
Pap & pelvic / Every 2 years <70
Prostate exam / Annual >50
Fecal blood / Annual 50-75
Tobacco Counsel / 8 per year
EKG / Once at IPPE
Vaccines
Pneumonia
Influenza
Hepatitis B
Shingles
TDaP / Once >65
Annual
By risk factor
Not covered
Not covered
Labs
Lipid Panel
Glucose
HIV
PSA / Every 5 years
Annual
By risk
Annual >50
SERVICE / FREQUENCY / LAST DONE / NEXT DUE / SCHEDULED
Mammogram / Annual >40
Colonoscopy / Every 10 yrs 50-75
Bone Density / Every 2 yrs >65
Aortic US / Once at IPPE
Glaucoma Screen / Annual for DM, FHX, AA>50, H>65
Diabetes Training / Annual for DM
Nutrition Training / Annual for DM/CRI
Advance Directives: / On chart / MD agrees / Family aware / Info Given
Living Will
Health Care Power of Attorney