Annual Wellness Visit

  • Annual Wellness Visit

    This is for medicare patients only
  • Date of Birth*
     - -
  • Todays Date
     - -
  • Rows

  • Alcohol Use Questionaire

    Because Alcohol use can affect health and interferewith certain medications and treatments, it is important that we ask you somequestions about your use of alcohol. Your answer’s will always remain confidential, so be as accurate aspossible.  Questions refer to standarddrinks.
  • (1) How often do you have a drink containing alcohol?*
  • (2) How many standard drinks do you have on a typical daywhen you are drinking*
  • (3) How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?*
  • (4) How often during the last year have you found that you were not able to stop drinking once you had started?*
  • (5) How often during the last year have you failed to do what was normally expected from you because of drinking?*
  • (6) How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?*
  • (7) How often during the last year have you had a feeling of guilt or remorse after drinking?*
  • (8) How often during the last year have you been unable to remember what happened the night before because you had been drinking?*
  • (9) Have you or someone else been injured as a result of your drinking?*
  • (10) Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?*
  • 11. Do you think you presently have a problem with drinking?*
  • 12. In the next 3 months, how difficult would you find it to cut down or stop drinking*

  • TOTAL SCORE INTERPRETATION: 

     A score of 8 or more is associated with harmful or hazardous drinking. 

     A score of 13 or more in women, and 15 or more in men, is likely to indicate alcohol dependence. 

  • Depression Screening

  • Rows

  • Anxiety Screening (GAD 7)

  • Rows

  • International Prostate Symptoms Score (IPSS) (MEN ONLY)

    (in women, hit next to bypass)
  • Rows
  • Nocturia: How many times do you typically get up atnight to urinate?

  • 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.

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

  • 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.

  • Social Determinants of Health (SDOH)

    Because social circumstances can impact your health, the following questions are asked to determine what can be done to help.
  • 1. Are you worried or concerned that in the next two months you may not have stable housing that you own, rent, or stay in as a part of a household?*
  • 2. Think about the place you live. Do you have problems with any of the following?(check all that apply)*
  • 3. Within the past 12 months, have you worried that your food would run out before you got money to buy more?*
  • 4. Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more.*
  • 5. Doyou put off or neglect going to the doctor because of distance ortransportation?*
  • 6. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?*
  • 7. Does problems getting childcare make it difficult for you to work or study?*
  • 8. Do you have a job?*
  • 9. Do youhave a high school degree?*
  • 10. Howoften does this describe you? I don’t have enough money to pay my bills:*
  • 11. Howoften does anyone, including family, physically hurt you?*
  • 12. How often does anyone, including family, insult or talk down to you?*
  • 13. How often does anyone, including family, threaten you with harm?*
  • 14. How often does anyone, including family, scream or curse at you?*
  • 15.Would you like help with any of these needs?*

  • 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: