Annual Wellness Assessment (HIPAA)

  • Annual Wellness Assessment

  • FOR DOCTOR USE ONLY

  • Date
     - -

  • PATIENT INFORMATION

  • Date of Birth*
     - -

  • BIOMETRIC MEASURES

  • SOCIAL RISK FACTORS

  • Do you presently drink alcohol?*
  • Do you feel alcohol interferes with your home or work life?*
  • Do you currently smoke cigarettes, cigars, a pipe, or vape?*
  • Are you interested in a plan to quit smoking?*
  • Do you wear a seatbelt in a car?*
  • Do you exercise regularly?*
  • Are you sexually active now?*
  • Do you see a dentist regularly?*
  • Do you have a healthcare proxy assigned?*

  • SELF ASSESSMENT

  • Do you consider yourself frail?*
  • Do you have any concerns about your nutrition?*

  • PSYCHOSOCIAL RISKS

  • Do you feel you suffer from any of the follow (check all that apply):*

  • ACTIVITIES OF DAILY LIVING

  • Are you able to dress alone?*
  • Are you able to maintain your own hygiene with a bath or shower?*
  • Are you able to shop alone?*
  • Are you able to do your own housekeeping?*
  • Are you able to handle your own finances?*
  • Are you able to get in and out of bed?*
  • Are you in need of any home services?*
  • Is your vision normal?*
  • Is your hearing normal?*
  • Are you able to cook for yourself and feed yourself?*
  • Have you recently fallen at home or do you ever lose your balance?*
  • Any falls, near falls or any other safety issues you wish to discuss?*
  • Are you able to walk without difficulty?*
  • Are you able to toilet without assistance?*
  • Are you able to use the telephone without assistance?*
  • Are you able to do your own laundry?*
  • Are you able to drive?*
  • Are you responsible for your own medication?*
  • Do you need assistance with your medication?*

  • PATIENT HEALTH QUESTIONNAIRE-9 (PHQ9)

  • Rows
  • If you put a 1 or higher for any of the above problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

  • (Healthcare professional: Add each column and then add each column total together for your final total. For interpretation of final total, please refer to PHQ-9 chart.)

  • CAGE Substance Abuse Screening

  • Have you ever felt you should ever cut down on your drinking?*
  • Have people annoyed you by criticizing your drinking?*
  • Have you ever felt bad or guilty about your drinking?*
  • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?*
  • Have you ever felt you should ever cut down on your drug use?*
  • Have people annoyed you by criticizing your drug use?*
  • Have you ever felt bad or guilty about your drug use?*
  • Have you ever used drugs first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?*
  • Date*
     - -

  • PATIENT HEALTH OTHER SPECIALTY PHYSICIANS

    PLEASE LIST ANY OTHER PHYSICIANS INVOLVED IN YOUR CARE

  • ANY OTHER PHYSICIANS NOT NOTED ABOVE

  • PREVENTATIVE EXAM NOTICE

  • You have made an appointment for a preventative medical visit. It is your responsibility as the patient to be aware of your insurance benefits. Please understan, we do not work for your insurance company, rather we work 100% for our patients. The recommended treatments and fees we charge will always be baed on the patients' individual needs.

    During the exam, if the PCP or the patient discuss a new or existing condition, the insurance will be billed appropriately. Benefit limitations, co-pays and/or deductibles may apply.

     

    I have read and understand the above policy. I acknowledge that I am responsible for any co-pay, deductible, co-insurance charges, and/or non-covered services.

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