Annual Wellness Visit

Annual Wellness Visit

This is for medicare patients only
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Todays Date

MonthDayYear
Date

All questions are completely confidential. The forms get scanned into your chart.*

	Yes	No	Skip
Do you get 3 servings of calcium-rich foods daily (milk, cheese, yogurt)?
Do you eat fruits and vegetables every day?
Do you limit the amount of fried food or fast food that you eat?
Are you easily able to get enough healthy food?
Do you drink a soda, juice drink, sports or energy drink most days of the week?
Do you often eat too much or too little food?
Do you have difficulty chewing or swallowing?
Are you concerned about your weight?
Do you exercise (walking, gardening, swimming) at least ½ hour a day?
Do you feel safe where you live?
Do you often have trouble keeping track of your medicines?
Are family members or friends worried about your driving?
Have you had any car accidents lately?
Do you sometimes fall and hurt yourself, or is it hard to get up?
Have you been hit, slapped, kicked, or physically hurt by someone in the last year?
Do you always wear a seat belt when driving or riding in a car?
Do you keep a gun in your house or place where you live?
Do you brush and floss your teeth daily?
Do you often feel sad, hopeless, angry, or worried?
Do you often have trouble sleeping?
Do you or others think that you are having trouble remembering things?
Do you smoke or chew tobacco?
Do friends or family members smoke in your house or place where you live?
In the past year, have you had more than 4 drinks at one time?
Do you use medicines to help you sleep, relax, calm down, feel better?
Do you have someone to help you make decisions about your health?
Do you need help bathing, eating, walking, dressing, or using the bathroom?
Do you have someone to call when you need help in an emergency?
Do you have other questions or concerns about your health?

Please include other health concerns you may have

Advanced Care Planning
As part of annual wellness, a key topic encouraged by Medicare and others has to do with “advanced care planning”. This refers to what should happen in case you are not able to make decisions about your health.

The goal of this is simply to get the person to at least start thinking about what their wishes would be since most people in their daily life don’t really think about this topic.

It can help to think of this by looking at a few scenarios: 1) If your heart were to stop or beat erratically, the normal response is to start chest compressions and possibly shock the heart if appropriate. (At the moment this is happening, we don’t really know if this is a long-term issue or not, we have to act right away Would you want the doctor to do the chest compressions and shock the heart. Also, quite often they need to put a tube in the airway (life support). 2) What if you have suffered a stroke and there is brain damage, at what stage of disability would you want your loved ones to decide that it is not a good idea to continue aggressive measures to extend life. 3) What if you have pneumonia and need to be placed on life support (it may be temporary), would you want your family members to agree that you be placed on a ventilator. Quite often people have trusts which typically state that in the event that there is brain death, they would not want life prolonged by artificial means. The phrase “brain death” is a very specific diagnosis in medicine and rarely used as it means the complete loss of all brain and brainstem activity. A person can have all the thinking activity of brain gone and still have brainstem function and that person is not considered brain dead.

A better phrasing would be to say significant brain damage which would impact quality of life. You would then have to define what that quality of life means to you and discuss with whomever you designate to make medical decisions for you. For some people it may mean that if they cannot walk, or speak or eat, then they would not want “heroic measures” to extend their life.
DNR: Do Not Resuscitate:
This is very specific. It means that you would not want to be resuscitated at all. It does NOT mean to not resuscitate if chances of survival are low. It means that a person who is DNR would not have their heart restarted via chest compressions or shocking of the heart. It also refers to not placing a tube in a person’s airway which is considered life support.
Do you have someone that you have designated who will make decisioons on your behalf in the event that you are not able to?*

NameRelationship
Have you discussed your wishes regarding advanced care planning with above named person(s)?*

YesNo
This form will be scanned into your chart in our office but will likely not be visible to any hospital that does not use Epic.

Privacy Policy
At Meena Medical Group, we are committed to protecting your privacy and ensuring the confidentiality of your medical information. This policy outlines how we collect, use, and safeguard your personal health information (PHI) in compliance with applicable laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA). Health information can be very sensitive and there are many bad actors around the world who target health information and so we take the responsibility to guard your information seriously.

We may collect the following types of information:

Personal identification information (name, address, phone number, email) Health information (medical history, treatment plans, medications) Payment information (insurance details, credit card information)

Your information may be used for the following purposes: To provide and manage your medical care

To communicate with you regarding appointments, treatment, and billing To process insurance claims and payments To comply with legal and regulatory requirements

We may share your information with: Healthcare providers involved in your care Insurance companies for billing purposes Third-party vendors who assist in operations (e.g., billing services, medical record management) As required by law or to protect our rights

Access your medical records Request corrections to your information Receive a list of disclosures made regarding your health information Request restrictions on certain uses and disclosures Request confidential communication methods

We implement appropriate technical and administrative safeguards to protect your information from unauthorized access, use, or disclosure. Our staff is trained on privacy and confidentiality practices.
Should be Empty:

	Not at all	Several Days	More than half the days	Nearly Every Day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed, or the opposite –being so fidgety or restless that you have been moving around a lot more than
Thoughts that you would be better off dead or of hurting yourself in some way

	Not at all	Several Days	More than half the days	Nearly Every Day
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

	Not at all	Less than 1/5 times	Less than ½ the time	About ½ the time	More than ½ the time	Every Day
Incomplete Emptying: How often have you had a sensation of not emptying your bladder completely after you finish urinating?
Frequency: How often have you had to urinate again less than two hours after you finished urinating?
Intermittency: How often have you found you stopped and started again several times when you urinated?
Urgency: How difficult have you found it to postpone urination.
Weak Stream: How often have you had a weak urinary stream?
Straining: How often have you had to push or strain to begin urinating?

Annual Wellness Visit

Alcohol Use Questionaire

Depression Screening

Anxiety Screening (GAD 7)

International Prostate Symptoms Score (IPSS) (MEN ONLY)

Advanced Care Planning

DNR: Do Not Resuscitate:

Social Determinants of Health (SDOH)

Privacy Policy