Annual Wellness Assessment (Non-Medicare) (HIPAA)

  • Annual Wellness Assessment

  • FOR DOCTOR USE ONLY

  • Date
     - -

  • PATIENT INFORMATION

  • Date of Birth*
     - -

  • 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*
     - -

  • 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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