Jump to Content

Available Forms

3. Medicare Wellness Health Assessment Questionnaire

___ Medicare Wellness Visit covers a yearly visit to discuss your plan of preventive care in the coming year. We ask you to fill-out a Wellness Health Assessment questionnaire. ___ Annual Wellness Visit is not a head-to-toe physical. Medicare does not cover a routine physical (RP). Medicare Wellness visit does not cover any RP blood work screening. But blood work may be ordered if you have been diagnosis or have enough "medical necessity" support. Your labs deductible and coinsurance will apply.

___ If you receive any additional services, blood works, tests, or screenings during the Annual Wellness Visit, then you may be charged your usual deductible and coinsurance. Services not included in the Annual Wellness Visit are billed separately. ___ If one or more of your chronic problems is not stable and/or you have some concern or issues and/or need changes, and require additional decision making then this will be BILL AS AN ADDITIONAL SERVICES TO THE WELLNESS VISIT and your deductible and coinsurance WILL APPLY. (Office: a separate evaluation and management (E/M) code could be billed with modifier 25)

___ For med refill: If your chronic problems (diabetes, hypertension, dyslipidemia, etc.) are stable, there's NO changes, NO issues or concern, and you are simply refilling medications, then this med refill should be reported with the Wellness visit. Any medication changes will be bill as additional services and your deductible/coinsurance office visit apply.



including estimate date, experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments:


. . . . .PREVENTIVE SERVICES - Screening for Sexually Transmitted Infections (STIs) and Counseling to Prevent STIs. For screening for chlamydia, gonorrhea, and syphilis in women at increased risk for STIs who are not pregnant report V74.5 and V69.8. For screening for syphilis in men at increased risk, report V74.5 and V69.8. Additional DX V22.0, V22.1, or V23.9 if pt pregnant. Coinsurance/deductible waived on counseling. Office visit coinsurance/deductible apply.

If No, you will let us know when have it done. If Yes, provide the approximate date mm/dd/yy.

No or Yes (need date if done)

If No, you will let us know when have it done. If Yes, provide the approximate date mm/dd/yy.

PREVENTIVE SERVICES - Glaucoma eye screening. Coinsurance/deductible apply. Factors at-risk if have 1) diabetes mellitus; 2) a family history of glaucoma; 3) are African-Americans aged 50 and older; 4) Are Hispanic-Americans aged 65 and older

Medicare doesn't cover routine hearing exams, hearing aids, or exams for fitting hearing aids. Medicare coverage for hearing rehabilitation services, including a comprehensive audiology assessment to determine if a hearing aid is appropriate. Coinsurance/deductible apply.

. . . . . (ALL means: Standing up from a sitting position, Getting dressed, Using the phone, Bathing or showering, Walking outside of the house, Walking in the house, Preparing meals, Eating a meal, Getting to the toilet, Getting to places beyond walking distance ie car/bus/taxi, Driving or getting to places, Grocery shopping, Housekeeping/doing Housework, Managing/taking own medications, and Handling your money/finances)

. . . . . Everyone eligible for annual PREVENTIVE Alcohol Misuse Screening G0442. For those who screen positive after the screening, 4 times per year for counseling G0443. Coinsurance/deductible waived on screening. Office visit coinsurance/deductible apply. (NOTE TO STAFF: if pt choose to cut down alcohol then type a note in pt chart inside ins area. initial___________)

. . . . Benefit of not smoking: 1) Extra money in your pocket. 2) No more smoky smell. 3) Food tastes so much better. 4) Healthier looking skin. 5) A quiet night's sleep - no snoring. 6) after 12hrs - carbon monoxide level in blood drop to normal. 7) after 2wks-3months - lung function improve. 8) after 1-9months - coughing and shortness of breath decrease. 9) coronary heart disease risk reduce. 10) stroke risk reduce. 11) lung cancer risk reduce. 12) Counseling to Prevent Tobacco Use - for Asymptomatic Beneficiaries. Coinsurance/deductible waived on counseling. Office visit coinsurance/deductible apply.

(tobacco include cigarettes, chew, snuff, pipes, cigars, vapor cigarettes)

. . . . . I understand the benefits about ceasing tobacco use: extra money, smell, tastes, skin, sleep,etc.

. . . . 20 minutes 3 or more days a week. . . . The Benefits of Physical Activity: 1) Control your weight. 2)Reduce your risk of cardiovascular disease. 3) Reduce your risk for type 2 diabetes and metabolic syndrome. 4) Reduce your risk of some cancers. 5) Strengthen your bones and muscles. 6) Improve your mental health and mood. 7) Improve your ability to do daily activities and prevent falls, if you're an older adult. 8) Increase your chances of living longer

. . . . Benefit: 1) Healthy eating helps prevent high cholesterol and high blood pressure and helps reduce the risk of developing chronic diseases such as cardiovascular disease, heart disease, cancer, stroke, and diabetes. 2) Healthy eating helps reduce one's risk for developing obesity, osteoporosis, iron deficiency, and dental caries - cavities. 3) Eat healthy food (as fresh fruits, fish and vegetables). Unhealthy food. ie fried foods, sweets and "junk food".

24. During the past 4 weeks, was someone available to help you if you needed and wanted help? For example, if you felt very nervous, lonely or blue, got sick and had to stay in bed, needed someone to talk to, needed help with daily chores, or needed help just taking care of yourself. ___

25. During the past 4 weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad or downhearted and blue? ___

26. Have you ever needed treatment for a mental health disorder such as depression, anxiety disorder, bipolar disorder or psychosis? ___

Home Safety and few recommendation to avoid falls. 1) Assess home for raised doorway thresholds. 2) Remove clutter, loose carpet, unsecured floor coverings. 3) Always maintain a clean dry floor. 4) No electrical cords in walk ways. 5) Maintenance of assistive devices. 6) Handrails in hallways. 7) Install grab bars in the bathroom. 8) Use non-skid mats inside and outside of shower/tub/toilet. 9) Use of appropriate bathing aides/chair. 10) Store household items on lower shelves so that you can access them easily. 11) Use reaching devices to access things that are higher than you can reach. 12) Wear low heeled, comfortable shoes that fit well. 13) Have night lights installed. 14) Keep home well lit. 15) Always make sure to sit up on the edge of the bed and get use to light before attempting to walk. 16) Smoke detectors at home. 17) Carbon monoxide detector.
. . . . Gait (walking characteristics / abnormality): A normal gait is characterized by the Pt walking with head erect, arms swinging freely at the side, and striding without hesitant. This gait scores 0. With a weak gait (score as 10), the Pt is stooped but is able to lift the head while walking without losing balance. Steps are short and the Pt may shuffle. With an impaired gait (score 20), the Pt may have difficulty rising from the chair, attempting to get up by pushing on the arms of the chair/or by bouncing (i.e., by using several attempts to rise). The Pt's head is down, and he or she watches the ground. Because the Pt's balance is poor, the Pt grasps onto the furniture, a support person, or a walking aid for support and cannot walk without this assistance. A limp is also considered a walking abnormality. A limp may be permanent or temporary.

29. Fall Assessment:

. . . .IV means Intravenous therapy / saline lock (infusion of liquid substances directly into a vein):

Mental status (Pt's own assessment of ability to walk): "Are you able to go the bathroom alone or do you need assistance?" If the Pt's reply judging his or her own ability is consistent with the ambulatory order on the Kardex®, the Pt is rated as "normal" and scored 0. If the Pt's response is not consistent with the nursing orders or if the Pt's response is unrealistic, then the Pt is considered to overestimate his or her own abilities and to be forgetful of limitations and scored as 15.

____ Total score. (00 - 24 points = NO Risk; 25 - 50 points = Moderate Risk. ; 51 or above = HIGH RISK.)

The following is Medicare Preventive Services:

Please record the last month and year you had the following. Estimate if you do not know the exact date. If you do not know, leave blank.

_____ Flu shots (pay $0, only cover once per flu season Aug - March)

_____ Hepatitis B shots (pay $0. only covers if at medium or high risk= Some risk factors include hemophilia, End-Stage Renal Disease (ESRD), diabetes, if you live with someone who has Hepatitis B, or if you're a health care worker and have frequent contact with blood or body fluids.)

_____Hepatitis C screening test (pay $0, one-time, repeat screening test if at high risk = current or past history of illicit injection drug use, had a blood transfusion before 1992, or were born between 1945 and 1965.)

_____ Pneumococcal shots- help prevent certain type of pneumonia (pay $0, one-time)

_____ Abdominal aortic aneurysm ultrasound screening (pay $0, one-time if at risk= family history of abdominal aortic aneurysms, or you're a man 65-75 and you've smoked at least 100 cigarettes in your lifetime)

_____ Alcohol misuse screening and counseling (1 yr, use alcohol, but don't meet the medical criteria for alcohol dependency.)

_____Bone density test - Bone Mass Measurements (pay $0, 24 months, repeat test if medical necessary)

_____Breast cancer screening - mammograms test (pay $0, 12 months, 40+) able have one baseline mammogram for women between 35-39

_____Cardiovascular disease - "CVD risk reduction visit". (behavioral therapy to help lower your risk, discuss aspirin use, check your blood pressure, tips to make sure you're eating well.)

_____ Cardiovascular disease blood test screening - cholesterol, lipid, lipoprotein, triglyceride levels (5 yr, pay $0 on labs plus ded/coins apply office visit)

____Diabetes glucose screening if at risk (pay $0 for test, up to 2 screening each yr)

_____Diabetes self-management training- eat healthy, active, monitor blood sugar, take med. (ded/coins apply)

_____ Electrocardiogram (EKG- during "Welcome to Medicare" one-time, ded/coins apply)

_____ Glaucoma eye disease if high risk= have diabetes, a family history of glaucoma, are African-American and 50 or older, or are Hispanic and 65 or older. (12 months, hi-risk, ded/coins apply)

_____HIV screening -Human Immunodeficiency Virus (1 yr, if at risk) if increased risk for the virus, people who ask for the test, or pregnant women

_____ Medical nutrition therapy services if have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months (pay $0, need referral)

_____ Obesity screening and counseling (BMI of 30 or more, up to 22 visit per 1 yr, pay $0)

_____ Depression test screening, follow-up, and referral (pay $0 for test plus ded/coins apply other svc)

_____Cervical and vaginal cancer screening - Pap and pelvic exam (24 months, if at risk then 12 months)

_____ Prostate Specific Antigen test (50+, 1 yr, PSA- pay $0, digital rectal-exam ded/coins apply)

_____ Sexually transmitted infection (STI) for chlamydia, gonorrhea, syphilis, and Hepatitis B (1 yr, if at risk, up to 2 face/face, pay $0 for test)

_____Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease, ded/coins apply)

Colorectal cancer screening (4 options)

_____ Option 1: Fecal occult blood test (pay $0, 1 yr, 50+)

_____Option 2: Flexible Sigmoidoscopy (4 yrs, or colonoscopy result not hi-risk then 10yr, pay $0)

_____ Option 3: Colonoscopy (10yrs, high-risk is 2yrs, 4yrs after flex. Sigmoidoscopy, coins apply)

_____Option 4: Barium enema (4yrs, hi-risk is 2yrs, coins apply)

* Required field