Annual Wellness Visit (AWV) Practice Checklist

Initial Annual Wellness Visit G0438 Dx V70.0) Subsequent Annual Wellness Visit G0439

Before the visit:

� Verify eligibility: [ ] Medicare [ ] Not eligible for Welcome to Medicare Visit [ ] More than 365 days since initial AWV

� Explain the Annual Wellness Visit to the patient

� Is the problem list complete?

� Is the medication list complete?

� Is the family history complete?

� Do we have a list of the patient’s other physicians?

During the visit:

� Have the patient complete a depression screen (initial AWV only)

� Have the patient complete functional assessment (initial and subsequent)

� Measure BP, weight, BMI and/or waist measurement

� Complete list of risk factors.

� Update immunization record and order immunizations.

� Update preventive checklist.

� Make new schedule of preventive and early detection interventions.

� Discuss advance directive.

� Refer for: [ ] Screening tests [ ] Nutritional interventions [ ] Treatment of depression [ ] Fall prevention [ ] Tobacco cessation

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A Checklist for Your Medicare Wellness Annual Visit

Please complete this checklist before seeing your doctor or nurse. Your answers will help you receive the best health care possible.

1. 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? Not at all Slightly Moderately Quite a bit Extremely 2. During the past 4 weeks, has your physical and emotional health limited your social activities with family friends, neighbors or groups? Not at all Slightly Moderately Quite a bit Extremely 3. During the past 4 weeks, how much bodily pain have you generally had? No pain Very mild pain Mild pain Moderate pain Severe pain 4. 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. Yes, as much as I wanted Yes, quite a bit Yes, some Yes, a little No, not at all

5 During the past 4 weeks, what was the hardest physical activity you could do for at least 2 minutes?

Very heavy Heavy Moderate Light Very light

Yes No 6. Can you get places out of walking distance without help? For example, can you travel alone by bus, taxi, or drive your own car?

7. Can you shop for groceries or clothes without help? 8. Can you prepare your own meals? 9. Can you do your own housework without help? 10. Can you handle your own money without help? 11. Do you need help eating, bathing, dressing, or getting around your home?

12. During the past 4 weeks, how would you rate your health in general? Excellent Very good Good Fair Poor 13. How have things been going for you during the past 4 weeks? Very well - could hardly be better Pretty good Good and bad parts about equal Pretty bad Very bad - could hardly be worse

Name:______________________________________ Date:___________________ Date of Birth:______________________________

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14. Are you having difficulties driving your car? Yes, often Sometimes No Not applicable, I do not use a car 15. Do you always fasten your seat belt when you are in a car? Yes, usually Yes, sometimes No 16. How often during the past 4 weeks have you been bothered by any of the following problems?

N

ever

Seld

om

Som

etim

ess O

ften

Alw

ays

Fall or dizzy when standing up Sexual problems Trouble eating well Teeth or dentures Problems using the telephone Tired or fatigued

17. Have you fallen 2 or more times in the past year? Yes No 18. Are you afraid of falling? Yes No 19. Are you a smoker? No Yes, and I might quit Yes, but I'm not ready to quit 20. During the past 4 weeks, how many drinks of wine, beer or other alcoholic beverages did you have? 10 or more per week 6-9 per week 2-5 per week 1 drink or less per week No alcohol at all

21. Do you exercise for about 20 minutes 3 or more days a week? Yes, most of the time Yes, some of the time No, I usually do not exercise this much. 22. Have you been given any information to help you with the following:

Hazards in your house that might hurt you? Yes No

Keeping track of your medications? Yes No 23. How often do you have trouble taking medicines the way you have been told to take them? I do not have to take medicine I always take them as prescribed Sometimes I take them as prescribed I seldom take them as prescribed 24. How confident are you that you can control and manage most of your health problems? Very confident Somewhat confident Not very confident I do not have any health problems.

How old are you? 65-69 70-79 80 or older Are you male or female? Male Female What is your race? (check one or more than one) White Black/African American Asian Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native Hispanic or Latino origin or descent Other

The content of this Medicare Wellness Checkup is adapted from www.HowsYourHealth.org and Copyright by the Trustees of Dartmouth College and FNX Corporation. Used by permission.

P A T I E N T H E A L T H Q U E S T I O N N A I R E - 9 ( P H Q - 9 )

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) Not at all

Several days

More than half the days

Nearly every day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3

7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3

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

0 1 2 3

9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3

FOR OFFICE CODING 0 + ______ + ______ + ______

=Total Score: ______

If you checked off any problems, 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 �

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

GAD-7

Over the last 2 weeks, how often have you been bothered by the following problems?

(Use “✔” to indicate your answer)

Not at all

Several days

More than half the

days

Nearly every day

1. Feeling nervous, anxious or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless that it is hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful might happen

0 1 2 3

(For office coding: Total Score T____ = ____ + ____ + ____ )

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

One drink equals:

12 oz. beer

5 oz. wine

1.5 oz. liquor (one shot)

1. How often do you have a drink containing alcohol? Never Monthly

or less

2 - 4 times a month

2 - 3 times a

week

4 or more times a week

2. How many drinks containing alcohol do you have on a typical day when you are drinking? 0 - 2 3 or 4 5 or 6 7 - 9 10 or

more

3. How often do you have four or more drinks on one occasion? Never Less than

monthly Monthly Weekly Daily or almost daily

4. How often during the last year have you found that you were not able to stop drinking once you had started?

Never Less than monthly Monthly Weekly

Daily or almost daily

5. How often during the last year have you failed to do what was normally expected of you because of drinking?

Never Less than monthly Monthly Weekly

Daily or almost daily

6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

Never Less than monthly Monthly Weekly

Daily or almost daily

7. How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than

monthly Monthly Weekly Daily or almost daily

8. How often during the last year have you been unable to remember what happened the night before because of your drinking?

Never Less than monthly Monthly Weekly

Daily or almost daily

9. Have you or someone else been injured because of your drinking? No

Yes, but not in the last year

Yes, in the last year

10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

No Yes, but

not in the last year

Yes, in the last year

0 1 2 3 4

Have you ever been in treatment for an alcohol problem? � Never � Currently � In the past

Patient name: ___________________ Date of birth: ____________________

I II III IV M: 0-4 5-14 15-19 20+ W: 0-3 4-12 13-19 20+

Alcohol screening questionnaire (AUDIT) Our clinic asks all patients about alcohol use at least once a year. Drinking alcohol can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below.

Which of the following drugs have you used in the past year?

� methamphetamines (speed, crystal) � cocaine

� cannabis (marijuana, pot) � narcotics (heroin, oxycodone, methadone, etc.) � inhalants (paint thinner, aerosol, glue) � hallucinogens (LSD, mushrooms) � tranquilizers (valium) � other ______________________________

How often have you used these drugs? � Monthly or less � Weekly � Daily or almost daily

1. Have you used drugs other than those required for medical reasons? No Yes

2. Do you abuse more than one drug at a time? No Yes

3. Are you unable to stop using drugs when you want to? No Yes

4. Have you ever had blackouts or flashbacks as a result of drug use? No Yes

5. Do you ever feel bad or guilty about your drug use? No Yes

6. Does your spouse (or parents) ever complain about your involvement with drugs? No Yes

7. Have you neglected your family because of your use of drugs? No Yes

8. Have you engaged in illegal activities in order to obtain drugs? No Yes

9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? No Yes

10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)? No Yes

0 1

Have you ever injected drugs? � Never � Yes, in the past 90 days � Yes, more than 90 days ago

Have you ever been in treatment for substance abuse? � Never � Currently � In the past

Patient name: ________________________ Date of birth: ________________________

I II III IV 0 1-2 3-5 6+

Drug Screening Questionnaire (DAST) Using drugs can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below.

Preventive Service Frequency Last Done Body Mass Index (BMI)____ Height _______ Weight _______

Annually

Blood Pressure _______/_______

• Every 2 yrs, if BP </= 120/80 mm hg; • Annually, if BP >120-139/80-89 mm hg

Vision

• Every 3 yrs up to age 40; • Every 2 yrs aged 40+

Breast Cancer Screening (Mammogram)

• Every 2 yrs, aged 50-74 yrs

Cervical Cancer Screening (Pap Smear)

• Every 3 yrs, aged 21-64 yrs; • Every 5 yrs, aged 30-65 with HPV

testing

Osteoporosis Screening (Bone Density Measurement)

• Routinely, for women aged 65+ • Routinely, for women aged 60-64 with

risk factors

Cholesterol Testing Regularly beginning at age 20 with risk factors

Diabetes Screening With a sustained BP >/= 135/80 mm Hg

Colorectal Cancer Screening • Annually, Fecal Occult Blood Stool (FOBS);

• Every 5 yrs, Sigmoidoscopy with FOBS; • Every 10 yrs, Colonoscopy

Sexually Transmitted Diseases (STD’s)

As necessary for those with risk factors

Depression Screening As necessary for those with risk factors

Alcohol Misuse Screening As necessary for those with risk factors

Immunizations: Pneumococcal (Pneumonia) Vaccine Influenza (Flu) Vaccine

• Pneumonia: 1-2 doses up to age 64; • Pneumonia: 1 dose age 65+ • Influenza: Annually

Other

Your major risk factors: Family history of ____________________ Obesity_______ Diabetes_______ Hypertension______ Fall Risk______ Smoking Use______ Other___________ Recommendations for improvement: Diet_____ Tobacco Cessation_____ Weight Management____ Exercise____ Other_____ Referrals

[ WOMEN’S PREVENTIVE WELLNESS PLAN

Patient Name______________________________ Date______________________________

atient Name

For Staff Use: [list handouts, referrals, or other followup instructions here]

Preventive Service Frequency Last Done Body Mass Index (BMI)____ Height _______ Weight ______

Annually

Blood Pressure _______/_______

• Every 2 yrs, if BP </= 120/80 mm hg;

• Annually, if BP >120-139/80-89 mm hg

Vision

• Every 3 yrs up to age 40; • Every 2 yrs aged 40+

Abdominal Aortic Aneurysm Once, between the age range of 65-75 and smoked 100+ cigarettes in lifetime

Cholesterol Testing Regularly beginning at age 20 with risk factors

Diabetes Screening With a sustained BP >/= 135/80 mm Hg

Colorectal Cancer Screening • Annually, Fecal Occult Blood Stool (FOBS);

• Every 5 yrs, Sigmoidoscopy with FOBS;

• Every 10 yrs, Colonoscopy

Sexually Transmitted Diseases (STD’s) As necessary for those with risk factors

Depression Screening As necessary for those with risk factors

Alcohol Misuse Screening As necessary for those with risk factors

Immunizations: Pneumococcal (Pneumonia) Vaccine Influenza (Flu) Vaccine

• Pneumonia: 1-2 doses up to age 64;

• Pneumonia: 1 dose age 65+ • Influenza: Annually

Other

Your major risk factors: Family history of ____________________ Obesity_______ Diabetes_______ Hypertension______ Fall Risk______ Smoking Use______ Other___________ Recommendations for improvement: Diet_____ Tobacco Cessation_____ Weight Management____ Exercise____ Other_____ Referrals

[ MEN’S PREVENTIVE WELLNESS PLAN

Patient Name______________________________ Date______________________________

atient Name

For Staff Use: [list handouts, referrals, or other follow-up instructions here]