CP2 | Medicare Wellness Visit Patient Intake

Demographics

Patient Name *

Date *

Provider *

Hospitalizations

List any hospitalizations, major illness or visits to the emergency room since last year or visit. Please include date of visit, reason for visit, and the location of visit.

Changes in Medications or Allergies Since Last Year or Visit

Changes in Medications

Please include the medication name, dosage, and the reason.

Changes in Allergies

Please include allergy name(s) and reactions.

Medical History

Coronary Disease Me
Father
Mother
Siblings
Children

Specify Coronary Disease(s)

High Blood Pressure Me
Father
Mother
Siblings
Children

Specify High Blood Pressure Disease(s)

High Cholesterol Me
Father
Mother
Siblings
Children

Specify High Cholesterol Disease(s)

Cerebral Vascular Disease / Stroke Me
Father
Mother
Siblings
Children

Specify Cerebral Vascular Disease(s) / Stroke(s)

List of Medical Equipment / Service Providers

Please include equipment name and who provides the equipment.

Name of all Providers / Specialists You See

Please include the provider / specialist name and reason you see them.

Cancer Me
Father
Mother
Siblings
Children

Specify Cancer(s)

Diabetes Me
Father
Mother
Siblings
Children

Specify Diabetes Disease(s)

Aortic Aneurysms Me
Father
Mother
Siblings
Children

Specify Aortic Aneurysm Disease(s)

Renal Disease Me
Father
Mother
Siblings
Children

Specify Renal Disease(s)

Past Surgeries

Please include name and date of operation(s).

Activities of Daily Living

Do you require assistance with any of the following activities? Using the telephone
Shopping
Meal preperation
Housekeeping
Laundry
Driving/taking taxi or bus
Taking medications
Handling finances
Eating
Getting from bed to chair
Dressing
Bathing
Toileting
Continence

I have someone available to help if needed (for a sick day)

Yes, any time
Yes, sometimes
Not really

Accident Prevention

Do you wear seat belts in the car?

Yes
No

Do you have smoke detectors at home?

Yes
No

Do you have carbon monoxide detectors?

Yes
No

Do you have a firearm at home?

Yes
No

If you do have a firearm, is it locked up?

Yes
No

Health Screening: Substance Use, Diet, Exercise, Fall Risk

Do you drink alcohol?

Yes
No

If you do drink alcohol, how many drinks per day / week?

Please indicate time period of day or week.

I no-longer drink alcohol

Have you ever smoked or chewed tobacco?

Yes
No

If you do use tobacco, how much per day?

Do you use marijuana or illicit drugs?

Yes
No

I'm interested in help to stop using

Diet

Balanced
Vegetarian
Diabetic
Low Sodium
Low Fat
Low Carb

Diet Other

Do you exercise every day?

Yes
No

If you don't exercise every day, how often?

Have you had any falls in the past year?

Yes
No

If you have had a fall in the past year, please list any injuries

Do you have trouble hearing?

Yes
No

Do you wear a hearing aid?

Yes
No

Last Hearing Exam

Do you have trouble seeing?

Yes
No

Do you wear glasses or contacts?

Yes
No

Last Eye Exam

Patient Health Questionnaire

Feeling bad about yourself - or that your are a failure or have let yourself or your family down