Your Appointment For The Welcome To Medicare Visit Or

Your appointment for the welcome to medicare visit or

File Name: Annual Medicare Wellness Visit Form.pdf

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Dear ___________________,
Your Appointment for the  Welcome to Medicare Visit OR Annual
Wellness Visit is scheduled on_____________ at _______
There is NO CO-PAY for this visit, so it is free for you

The goal of this visit is to provide time for you to discuss with your doctor, areas of
your health that may put you at risk for problems in the future

As part of the visit, you will be screened for fall risk, safety risk, worsening memory,
depression and other medical concerns

This is NOT a “full physical”, but a time to review your medical history and make
certain that appropriate screening tests have been performed

This visit WILL NOT include treatment or management of problems

Examples of things not covered in the Annual Wellness Visit are:
 Refills of chronic medications or prescription of new medications
 Evaluation of status of chronic diseases such as diabetes, high blood pressure,
high cholesterol, heart disease, arthritis, urinary symptoms
 An actual physical exam (such as looking at the skin, listening to the heart and
lungs, examining the abdomen)
 Blood tests to follow any condition you are known to have

In order to help the visit run smoothly, please complete the enclosed forms and bring
them with you to your visit. Try to complete as much as you can before your
appointment. The information will help you and your doctor better understand what
screenings you should get and what to watch for in the future

If you arrive at the office without these forms, your visit may need to be

Please make sure to be on time and call with more than 24 hours’ notice if you cannot
make your appointment

If you have questions regarding this visit, please speak with your doctor

We look forward to seeing you soon

Page 1 of 6
Rev 03.12
Please complete this questionnaire as thoroughly as possible. This confidential
history will be part of your permanent records and will help us get a better
understanding of your overall health. THANK YOU!
NAME:______________________________________ Age:______ DOB:_________ Today’s Date: ___________
Social History ✓ all that apply:
Tobacco Use:  Cigarettes  Never  Prior use Quit Date: ___________
 Chew
Frequency: ____ cigs/packs day/week # of yrs: __________
 Cigars
 Snuff Are you interested in quitting?  Yes  No
 2nd hand
Alcohol:  Never  Occasional  Daily
Caffeine:  Never  Occasional  Daily
Drug’s:  Never  Occasional  Daily  Prior Quit Date:
Occupation: Exercise: (type/frequency)
Home Environment:  Private home  Assisted living  Other: (describe)
Family History – use ✓ to indicate positive history
Self Father Mother Brothers Sisters Aunts Uncles Daughters Sons
Heart disease
Kidney Disease
Genetic disorder
Liver disease
Colon cancer
Breast cancer
Other Cancer
Page 2 of 6
Rev 03.12
NAME:______________________________________ PATIENT SECTION
Have had any Hospital Visits?  NO YES If yes:
Reason Date Where
Have you had any Past Surgeries?  NO  YES If yes:
Type/Reason Date Where
Do you have any Allergies:  NO YES If yes:
Allergy to what? What type of reaction?
Please list all of your current medications, including VITAMINS, HERBS, OVER THE COUNTER
Have you discussed taking a daily aspirin with your doctor?  Yes  No
Page 3 of 6
Rev 03.12
NAME:______________________________________ PATIENT SECTION
Please list any Chronic Medical Problems:
Please list any Acute or New medical problems (will not be discussed in full today)
been going on?
Please list all other providers that you see; please include therapists, chiropractors, acupuncturists,
nutritionists, etc:
PROVIDERS NAME What do you see them for?
Page 4 of 6
Rev 03.12
NAME:__________________________________-________ PATIENT SECTION
Do you have a problem hearing the telephone?
Do you have trouble hearing the television or radio
Do people complain that you turn the TV volume up too high?
Do you have to strain to understand conversation?
Do you find yourself asking people to repeat themselves?
Do many people you talk to seem to mumble (or not speak clearly)?
Do you live alone?
Does your home have rugs in the hallway?
Do you need help with the phone, transportation, shopping, meals, housework, laundry
Does your home LACK grab bars in bathrooms, handrails on stairs and steps?
Does your home LACK functioning smoke alarms?
Does bending over increase dizziness or imbalance?
Do you restrict travel for business/recreation due to your imbalance?
Are you afraid to leave the house alone due to dizziness or imbalance problems?
Have you fallen in the past year?
How many days a week do you usually exercise? ________ days per week
On days when you exercise, for how long do you usually exercise? ______ minutes per day  Does not apply
How intense is your typical exercise? (check one)  I am currently not exercising  Light(like stretching or slow walking)
 Moderate (like brisk walking)  Heavy (like jogging or swimming  Very heavy (like fast running or stair climbing)
Are you on a special diet?  Yes  No If yes, why?
On a typical day, how many servings of fruits and/or vegetables do you eat? ________ servings per day
(1 serving = 1 cup of fresh vegetables, ½ cup of cooked vegetables, or 1 medium piece of fruit, 1 cup = size of a baseball)
On a typical day, how many servings of high fiber or whole grain foods do you eat? ______ servings per day
(1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole-grain or high-fiber ready-to-eat cereal,
½ cup of cooked cereal such as oatmeal, or ½ cup of cooked brown rice or whole wheat pasta)
On a typical day, how many servings of fried or high-fat foods do you eat? ______ servings per day
(Examples include fried chicken, fried fish, bacon, French fries, potato chips, corn chips, doughnuts, creamy salad dressings,
and foods made with whole milk, cream, cheese, or mayonnaise)
Do you always fasten your seat belt when you are in the car? Yes  No
Do you ever drive after drinking, or ride with a driver who has been drinking? Yes  No
Do you protect yourself from the sun when you are outdoors? Yes  No
Page 5 of 6
Rev 03.12
NAME:_________________________________ ________ PATIENT SECTION
How often is stress a problem Never/rarely Sometimes Often Always
for you?    
How well do you handle the I’m usually able to At times I have I often have
stress in your life? cope effectively problems coping problems coping
  
How many hours of sleep do you usually get each night? ___________________
In general, would you say your health is: Excellent Very good Good Fair Poor
    
How often do you get the social and Always Usually Sometimes Rarely Never
emotional support you need:     
In general, how satisfied are you with Very Satisfied Dissatisfied Very
your life: satisfied   dissatisfied
 
Over the last 2 weeks, how often have you been bothered by any (0) (1) (2) (3)
of the following: Not at Several More Nearly
all Days than half every
(Check the appropriate box to the right) the days day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless

3. Trouble falling/staying asleep, sleep too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself – or that you are a failure or have
let yourself or your family down

7. Trouble concentrating on things, such as reading
the newspaper or watching television

8. 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 usual

9.Thoughts that you would be better off dead or of hurting yourself
in some way

A. 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?  Not difficult at all  Somewhat difficult Very difficult  Extremely difficult
B. In the past two years have you felt depressed or sad most days, even if you felt okay sometimes?
 Yes  No
Physician/Provider signature: ________________________________________
Page 6 of 6
Rev 03.12

Page 1 of 6 Rev 03.12 Dear _____, Your Appointment for the Welcome to Medicare Visit OR Annual Wellness Visit is scheduled on_____ at _____ There is NO CO-PAY for this visit, so it …

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Frequently Asked Questions

What does the welcome to medicare visit include?

  • Past medical records including any x-ray and lab reports
  • Immunization records
  • A list of all prescription and over-the-counter medications you take regularly
  • Your family medical history, especially information about hereditary conditions
  • Any existing advance directives or other health decision-making documents

More items...

What does welcome to medicare mean?

“Welcome to Medicare” package (not automatically enrolled) What is it? This welcome package is the first mail you'll get from Medicare. It includes a letter, booklet, and Medicare card. The booklet explains important decisions you need to make now that you have Medicare. It's sent to people who: Go to Social Security to sign up for Medicare

What is the welcome to medicare wellness visit?

In addition to collecting a medical history, it may also include a vital signs check, lung exam, head and neck exam, abdominal exam, neurological exam, dermatological exam, and extremities exam. Clinical laboratory tests are notincluded in either the Welcome to Medicare Visitor Annual Wellness Visit.

Will medicare cover the costs of my doctor visits?

Medicare may cover doctor visits if certain conditions are met, but in some cases, you’ll have out-of-pocket costs, like deductibles and coinsurance amounts. No matter what kind of Medicare coverage you may have, it’s important to understand that your doctor must accept Medicare assignment.