GA Aetna/Ohio Follow-up Assessment

GA Aetna/Ohio Follow-up Assessment
Reminder: Please verify identifiable data such as birthdate or address, and give relevant disclosures.
Plan
Date*

MonthDayYear
Date
GA Client ID*
Member ID*
Name*

First NameLast Name
DOB*

MonthDayYear
Birthdate
Height*
Weight*
BMI*
Check all health condition(s) that apply to this client:*

Mental Health IllnessSubstance AbuseEating DisorderDiabetes/Pre-DiabetesAsthmaCystic FibrosisDown syndromeCelebral PalsyCancerDevelopmental delaysAutismOther
Are any of these diagnoses new (from the last visit?)*

YesNo
If Yes, list condition(s) here:
In the past 6 months, have you been in the hospital, emergency room or a inpatient facility?*

YesNoUnsure
If Yes/Unsure, please list any additional information provided (or why they were hospitalized):
Assessment: Seeking Nutrition Education For:*
Nutritional Diagnosis/Nutrition Education Needs*
Intervention*
Monitoring/Evaluation*
RD Summary
Additional Nutrition Appointments Requested*
Visit codes
Name of RD conducting this assessment*
# of mins spent on call*
Do any of the following apply?

Z5941 Food insecurityZ550 Illiteracy and low-level literacyZ597 Insufficient social insurance and welfare supportZ602 Problems related to living aloneZ604 Social exclusion and rejectionZ62819 Personal history of unspecified abuse in childhoodZ630 Problems in relationship with spouse or partnerZ634 Disappearance & death of family memberZ635 Disruption of family by separation and divorceZ636 Dependent relative needing care at homeZ6372 Alcoholism and drug addiction in familyZ651 Imprisonment and other incarcerationZ658 Other specified problems related to psychosocial circumstancesZ5948 Other specified lack of adequate food
GA Customer Care Phone: 1-866-575-2772
GA Customer Care E-mail: carecenter@gafoods.com
Should be Empty: