Your Appointment For The Welcome To Medicare Visit Or
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File Name: Annual Medicare Wellness Visit Form.pdf
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Summary
Dear ___________________,Your Appointment for the Welcome to Medicare Visit OR AnnualWellness 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 ofyour 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 makecertain 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 bringthem with you to your visit. Try to complete as much as you can before yourappointment. The information will help you and your doctor better understand whatscreenings 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 berescheduled
Please make sure to be on time and call with more than 24 hours’ notice if you cannotmake 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 MEDICARE WELLNESS VISIT 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 SonsDeceasedHypertensionHeart diseaseStrokeKidney DiseaseObesityGenetic disorderAlcoholismLiver diseaseDepressionColon cancerBreast cancerOther CancerOther: Page 2 of 6 Rev 03.12 NAME:______________________________________ PATIENT SECTIONHave had any Hospital Visits? NO YES If yes: Reason Date WhereHave you had any Past Surgeries? NO YES If yes: Type/Reason Date WhereDo 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 COUNTERMEDICATIONS and SUPPLEMENTS MEDICATION OR DOSE, HOW MEDICATION OR DOSE, HOW SUPPLEMENT MANY SUPPLEMENT MANY TIMES A DAY TIMES A DAY Have you discussed taking a daily aspirin with your doctor? Yes No Page 3 of 6 Rev 03.12 NAME:______________________________________ PATIENT SECTIONPlease list any Chronic Medical Problems: MEDICAL CONDITION DOCTOR WHO MANAGES YEAR DIAGNOSEDPlease list any Acute or New medical problems (will not be discussed in full today) MEDICAL CONDITION DOCTOR WHO MANAGES How long has this 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 HEARING SCREENING: Yes No 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)?BALANCE/ SAFETY/ FALL SCREENING Yes No Some TimesDo you live alone?Does your home have rugs in the hallway?Do you need help with the phone, transportation, shopping, meals, housework, laundryDoes 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?EXERCISEHow many days a week do you usually exercise? ________ days per weekOn days when you exercise, for how long do you usually exercise? ______ minutes per day Does not applyHow 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)NUTRITIONAre 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)MOTOR VEHICLE SAFETYDo you always fasten your seat belt when you are in the car? Yes NoDo you ever drive after drinking, or ride with a driver who has been drinking? Yes NoSUN EXPOSUREDo you protect yourself from the sun when you are outdoors? Yes No Page 5 of 6 Rev 03.12 NAME:_________________________________ ________ PATIENT SECTION GENERAL WELL-BEING 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 DEPRESSION SCREENING: PHQ-9Over 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 day1. Little interest or pleasure in doing things2. 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 havelet yourself or your family down
7. Trouble concentrating on things, such as readingthe newspaper or watching television
8. Moving or speaking so slowly that other people could havenoticed. Or the opposite – being so fidgety or restless that you havebeen 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 difficultB. 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
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.