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Annual Health Assessment 2012

Health Plan Name: Member Name: Provider Name: Date of Birth: Gender: F M

Cross Reference Number: (Do not write on this area for official use only)

Date of Visit: Member ID: Billing NPI: Rendering NPI:

MM/DD/YYYY

MM/ DD/YYYY

PRESENT, PAST AND SOCIAL HISTORY:

History of Present Illness: Recent Hospitalization? Yes No Date: Recent Surgery? Yes No Date:

Family History
Condition
DM CVD Cholesterol Cancer Alzheimer Other:

General Counsel / Habits

Siblings Counsel if at risk for STDs: At risk for HIV: Counsel on tobacco use: Counsel on illicit drug use: Counsel on alcohol misuse: Yes Yes Yes Yes Yes No No No No No N/A N/A N/A N/A N/A

Mother

Father

Family Environment (e.g. Live with spouse, caregiver etc.): Transportation: Self Depends on: Yes No Allergies: Date: Yes No

Discussion regarding Advance Directives?

Advance Directives on file at: Office / Hospital Comments:

Medication Review: Patient / Caregiver

Questions Yes No

1. Patient has knowledge his/her medications by name/use. 2. Patient can identify the frequency of his/her medications. 3. Patient administrates medications as prescribed.

Past Medical History:

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Annual Health Assessment 2012

PHYSICAL EXAMINATION
Vital Signs: T _______C Pulse _______ / min R ______ / min
HEENT / Oral NECK Chest. including Breast & Axilla Abdomen Genitalia, Groin, Buttocks Back Each Extremity, Including Pulses Skin Neurologic Psychiatric Hematologic/Lymphatic/Immunologic WNL WNL WNL WNL WNL WNL WNL WNL WNL WNL WNL

Blood Pressure: ______ / ______ Ht ______ / ______ Wt _______lbs BMI: _______

Abnormal: Abnormal: Abnormal: Abnormal: Abnormal: Abnormal: Abnormal: Abnormal: Abnormal: Abnormal: Abnormal:

NUTRITION
Nutrition
Morbid Obesity (BMI > 40): Hemoglobin: Serum Albumin: Recent Weight Change: Dietary counseling for weight loss or related chronic disease: Yes Yes No No

Results
Yes No

Active Diagnosis (if any)

Plan / Goals / Treatment / Intervention / Follow-up

COGNITIVE ASSESSMENT: Six-Item Screener (SIS)

Orientation: _____Yes ____ No 1) 2) 3) Day of the week Month of the month Year Three-Item Recall: (Derived from the MMSE) 1) Ball 2) Flag 3) Tree

WNL

* Each item scores one point, a lower score than 4 signifying more cognitive impairment. Please complete the full minimental study.

Diagnosis

Plan / Goals / Treatment /Intervention / Follow-up

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Annual Health Assessment 2012

MAJOR DEPRESSION INVENTORY
How much of the time have you :
1 2 3 4 5 6 7 8a 8b 9 10a 10b Felt in low spirits or sad Lost interest in your daily activities Felt lacking in energy and strength Felt left self-confident Had a bad conscience or feelings of guilt Felt that life wasn't worth living Had difficulty in concentrating, e.g. when reading the newspaper or watching television Felt very restless Felt subdued Had trouble sleeping at night Suffered from reduced appetite Suffered from increase appetite
All of the Time Most of the Time More Than Half of the Time Less Than Half of the Time Some of the Time At No Time

5 5 5 5 5 5 5 5 5 5 5 5

4 4 4 4 4 4 4 4 4 4 4 4

3 3 3 3 3 3 3 3 3 3 3 3

2 2 2 2 2 2 2 2 2 2 2 2

1 1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0 0

Scoring of the Major Depression Inventory

1) 2) 3) Each item is scored on a Likert scale from 0-5. For items 8 and 10, chose the sub item (a or b) with the highest score. When measuring treatment outcome, the sum of the ten items is used. A higher score signifies deeper depression. When using the scale in the diagnosis of depression there are the following possibilities:

Mild Moderate Depression: A score of 4 or 5 in two of the first three items, plus a score of 4 or
5 in at least four of the last seven items.

Severe Depression: A score of 4 or 5 in all of the first three items, plus a score of 4 or 5 in at least five of the last seven items.
*Major Depression: The number of items is reduced to nine, as item 4 is a part of item 5. The item (4 or 5) with the highest score is included. There must be a score of 4 or 5 in at least five of the nine items, of which one must be either item 1 or 2.
4)

Depression Treatment:

*Requires referral to Behavioral Health (Required Field

FALL RISK SCREENING

1. 2. 3. 4. 5. 6. 7. 8. 9. Diagnosis (3 or more coexisting that increase fall risk) Prior history of falls within 3 months Incontinence Visual Impairment Impaired functional mobility (e.g. Hemiplegic , Amputation, Hemiparesis) Environmental Hazards (e.g. stairs, bathtub and shower high, lighting) Polypharmacy (4 or more medications) Chronic pain affecting level of function (Neuropathy, Lumbalgia. etc.) Cognitive impairment. (e.g. Alzheimer Decease, Mental Retardation, Senile Dementia, etc.) a. b. c.

Yes = 1 point

No = 0 points

Total Points (4 or more is considered at risk) Provide anti-slippery socks to avoid risk fall.

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Annual Health Assessment 2012

PAIN SCREENING:
1. 2. Does the patient have a complaint of acute or chronic pain? Yes No Indicate where pain is located ______________________________________

Intensity:
On a scale of 0 to 10 with 0 being No Pain and 10 being Pain as bad as you can imagine rate the pain you are experiencing now What treatments or medications are you using to manage your pain? ______________________. In the past, how much reliefs have pain treatments or medications provided?
No Relief

0%

50%

Has pain interfered with any of the following: (Use and legible handwriting)

Complete Relief

100%

Bathing/Dressing

Mood

Walking Ability Enjoyment of Life

Employment Transportation

Housework Toileting

Sleep Food Preparation

Relationships with Others

Pain Management Plan: Pain due to: Plan / Goals / Treatment / Intervention / Follow-up

Pain Management Plan:

Pain Management Plan:

SCREENING SCHEDULE Medicare Covered Test/Screening/Service

Bone Mineral Density (BMD) Cardiovascular (LDL, Beta-blocker after MI) Colorectal Cancer Screening (one of the three): Fecal Occult Blood Test Colonoscopy Flexible Sigmoidoscopy Diabetes Screening (eye exam, LDL, HGA1C,GFR) Diabetes Self-management Training Flu Shot (Yearly) Glaucoma Test Mammogram (Female) Prostate Cancer Screening (Male) Pneumococcal Shot

Recommended (if Done, add the date)

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No Done Done Done Done Done Done Done Done Done Done Done

Frequency

MM/DD/YYYY

Follow-up recommended, mark all that apply:

1. 2. 3. Wound care follow-up; wound located at: Social services due to: No caregiver for ADL Other, specify: Lives alone Not sufficient income to cover all needs Intervention for inappropriate BMI

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Annual Health Assessment 2012

FOOT EXAM (If Diabetic) NO Acute swelling and/or Acute deformity ...... Skin breakdown (ulcer): ..... Callus - with deeper color changes .... Toe Deformity or chronic midfoot/rearfoot prominen .. History of amputation and/or ulceration ..... Dystrophic Nails and/or Dry Skin . Neuropathy: using 10-gram nylon monofilament performed yearly 4 out of 10 sites imperceptible = positive result .
Assign Risk Category:

YES

N/A

0 1 2

No Present Risk No loss of protective sensation, no deformity. Impending Risk No loss of protective sensation. Deformity present. High Risk Loss of protective sensation with or without weakness, deformity, callus, pre-ulcer or history of ulceration.
Adapted from the National Foot Treatment Center LEAP Program

Foot Pulses:
Foot
Right Left

Pulses
Dorsalis Pedis Posterior Tibialis Dorsalis Pedis Posterior Tibialis

Palpable

NON palpable

Swelling, skin breakdown, decreased pulses, deep color changes = PVD 2nd to diabetes. 4 out of 10 sites without sensation to light touch with monofilament = neuropathy 2nd to diabetes.

Diagnosis (if apply)

Plan / Goals / Treatment / Intervention / Follow-up

Referral for diabetic foot care, reasons:

Activities of Daily Living (Use and legible handwriting) Bathing Dressing and Undressing Eating Transferring from bed to chair, and back Voluntarily control urinary and fecal discharge Using the toilet Walking (not bedridden)

Independent

Dependent

Comments

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Annual Health Assessment 2012

Physician Name: Plan: Member ID Gender: Member Name: Hospital Affiliation: Date of Visit:

MM/DD/YYYY

Date of Birth:

MM/DD/YYYY

PROBLEM / DIAGNOSIS / ASSESMENT

DIAGNOSIS / DESCRIPTION
MONITORING / EVALUATION / ASSESSMENT / ADDRESSING / TREATMENT
List of current providers or suppliers that are regularly involved in providing medical care and list of current medication

1.

2.

3.

4.

5.

6.

7.

8.

9.

Note: All medications should also include the Corresponding Number(s) on the Problem List that the Medication is treating.
Completed assessment of patients preventive health care needs
Yes No. The diagnoses reflected herein are truthful, accurate and reflect my personal clinical judgment.

By signing, I represent and acknowledge that both Physical Examination and Clinical Condition Assessment sections of the AHA form have been thoroughly completed and the information included in this form, including any diagnoses outlined here, is (i) truthful and accurate to the best of my knowledge and understanding (ii) based upon a face to face medical evaluation performed on this patient as well as other information that I consider relevant in the exercise of my best professional judgment, (iii) I understand that payment of this claim will be from federal and state funds and that any falsification or concealment of a material fact maybe prosecutes under federal and state laws. (iiii) to if after auditing the AHA the Health Plan determines that the information is not accurate or non-compliant, MMM/PM reserves the right to validate and code the diagnosis described by the physician in the AHA form.

Signature: License #

PA

MD

DO

NP