GIMG (Initial Chart)

Step 1 of 22

ROUTE SHEET

Initial Visit

Patient Name:

Date of Service:

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone:

Patient's Signature:

Date

MM slash DD slash YYYY

Patient is unable to sign. Reason:

Authorized Person's Signature:

Name of Signatory:

Date

MM slash DD slash YYYY

Relationship to the Patient:

Signature over Printed Name

Start Time:

Hours

Minutes

AM/PM

End Time:

Hours

Minutes

AM/PM

Date

MM slash DD slash YYYY

PATIENT REGISTRATION FORM

PATIENT INFORMATION

Patient Name:

Date:

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

HOME PHONE:

CELL NO.

OTHER CONTACT NO.

RACE:

LANGUAGE:

MARITAL STATUS:

INSURANCE INFORMATION

MEDICARE ID NUMBER:

SSN:

EMERGENCY CONTACT

NAME:

PHONE NO.

RELATIONSHIP TO PATIENT:

ADDRESS OF EMERGENCY CONTACT:

RECENT MEDICAL VISITS / SERVICES

Date

MM slash DD slash YYYY

TYPE OF VISIT/SERVICE

Date

MM slash DD slash YYYY

TYPE OF VISIT/SERVICE

Date

MM slash DD slash YYYY

TYPE OF VISIT/SERVICE

RECORDS RELEASE AUTHORIZATION

I, ____________________________________________________, hereby authorize GLOBAL INTEGRATED MEDICAL GROUP d/b/a GIMG to share / release / disclose the below listed medical records with the individuals / entities / companies listed below.

Medical records to be shared / released / disclosed:

Medical history

Current diagnosis(es)

Referrals / Orders

Treatment plans

Clinical notes

Any other information obtained from today’s, previous, and future visits

Individuals / entities / companies authorized to receive copies of the aforementioned medical records:

Patient Name:

MBIN:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth:

MM slash DD slash YYYY

Age:

Sex:

Male

Female

PATIENT OR AUTHORIZED PERSON’S SIGNATURE

DATE

MM slash DD slash YYYY

IF DIFFERENT FROM PATIENT:

Name of Signatory:

Relationship to Patient:

CONSENT FOR TREATMENT, ACKNOWLEDGMENT
OF HIPAA NOTICE, AND DISCLOSURE OF PHI

CONSENT

I, ____________________________________________________, hereby voluntarily give consent to GLOBAL INTEGRATED MEDICAL GROUP, and its associated Physicians, Nurse Practitioners, Physician Assistants, Clinicians and all other personnel (collectively GIMG) to perform all medically necessary assessments and treatments today and on all future visits. I understand that I may refuse or terminate services at any time, and understand that no guarantee has been or can be made as to the results of any treatments. I further understand that I can discuss any religious or personal, cultural, and other preferences that are important to me in fulfilling my treatment plan. I authorize photographs and videos to be taken for the documentation and support of any diagnosis(es) only. I understand photographs and videos may be used to track the progress of illnesses/diseases/ complaints.

HIPAA NOTICE / NOTICE OF PRIVACY PRACTICES

I, ____________________________________________________, understand that I have the right to request a copy of the HIPAA notice / Notice of Privacy Practices of GIMG. I confirm that I was given an opportunity to ask questions and voice any concerns as they pertain to the dissemination of my information. I give permission to GIMG to use and disclose my Protected Health Information (PHI) to carry out any treatment plans, health care arrangements, and referrals and orders as it may be needed.

DISCLOSURE OF PHI FOR PAYMENT

I, ____________________________________________________, consent to the use and disclosure of my PHI for the purposes of obtaining payment of authorized benefits for services rendered to me from Medicare, Medi-Cal, and any other responsible payers, to be made to GLOBAL INTEGRATED MEDICAL GROUP on my behalf.

PATIENT OR AUTHORIZED PERSON’S SIGNATURE:

Date:

MM slash DD slash YYYY

MEDICATION RECONCILIATION

Patient Name:

Date:

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

Pharmacy:

Phone:

Drug Allergies:

NEW PRESCRIPTION / MODIFICATIONS / TO BE DISCONTINUED (STATE REASON FOR CHANGE)

DR.

Date

MM slash DD slash YYYY

ASSESSMENT FOR FOLLOW-UP VISIT (SOAP NOTES)

Patient Name:

Date

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

TELEHEALTH VISIT (Visit conducted via encrypted 2-way audio-visual communication)

CHIEF COMPLAINTS

HISTORY OF PRESENT ILLNESS

FUNCTIONAL ABILITY ASSESSMENT

Patient is independent in all ADLs

Patient needs help with:

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Bathing

Toileting

Hygiene

Dressing

Grooming

Housekeeping

Eating/Feeding self

Meal Preparation

Medication Management

Stairs

Transferring

Shopping

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Patient requires assistance with Ambulation/Mobility

Patient has Bladder or Bowel Incontinence

Patient uses an assistive device

Yes

specify if yes:

Cane

Walker

Crutches

Wheelchair

Bedbound

Patient has difficulties ambulating within home

Yes

Obstacles making ambulation difficult for patient:

Yes

specify if yes:

Stairs

Clutter

Slippery surfaces

Patient has assistance in home

Yes

Who:

Frequency:

Concerns or evidence of elderly abuse present

Yes

If yes, describe:

Patient is a fall risk

Yes

If yes, indicate number of fall episodes patient had in the last year:

> 2

If with fall(s), indicate injuries sustained:

None

Injuries

Injuries:

Patient suffers from hearing loss

Yes

if yes:

Patient uses hearing aid(s)

No hearing aid(s)

Patient suffers from poor vision

Yes

if yes:

Patient uses glasses

No glasses

Date

MM slash DD slash YYYY

ASSESSMENT FOR FOLLOW-UP VISIT (SOAP NOTES)

Patient Name:

Date:

Age:

Date of Birth:

Sex:

Male

Female

PHYSICAL EXAMINATION

Family History:

None

HTN

CAD

Heart Attack

HLD

Stroke

Other:

Medical History:

None

HTN

CAD

Heart Attack

HLD

Stroke

Other:

Surgical History: (Include hospital stays, operations, etc.)

Social History: If yes, how often?

Uses or smokes tobacco:

Yes

Daily

Several times a week

Few times a week

Social

Consumes alcohol:

Yes

Daily

Several times a week

Few times a week

Social

Uses recreational drugs:

Yes

Daily

Several times a week

Few times a week

Social

Last Colonoscopy:

Last ECG:

Last Mammography:

VITALS

Height

Temp

°F

Weight

lbs

mmHg

BMI

bpm

O2 Sat

REVIEW OF SYSTEMS

Gen:

Change in Appetite | Weight change:

Loss

Gain

Night sweats

F/C

Fatigue

Others:

Eyes:

Vision Change

Blurry

Double:

Eye pain:

D/C:

Others:

ENT

Sore throat

Sinus Pain

Hearing loss:

Tinnitus:

Ear Pain:

Others:

Pulm:

SOB:

At rest

On Exertion

Cough

Hemoptysis

Wheezing

OSA

Others:

CV:

Palpitations

Orthopnea

Arrhythmia

CAD

CABG

Syncope

Aneurysm

Others:

GI:

N/V

Abdominal pain

D/C

GERD

PUD

IBS

Colitis

Melena

Hematemesis

Hematochezi

Diarrhea

Constipation

Bowel Incontinence

Last BM:

GU:

Dysuria

Hematuria

Frequency

Urgency

Nephropathy

Renal Failure

Renal Stones

Urine Incontinence

Stress Incontinence

Urge Incontinence

Mixed Incontinence

Functional Incontinence

MSK:

Back Pain

LBP

Radiating to LE

Stiffness

Myalgia

Others:

Pain:

Location:

Description:

Frequency:

Intensity (1–10):

Tx:

Intensity After Tx:

Endo:

Thyroidism:

Hypo

Hyper

Others:

Neuro:

Numbness

H/A

Dizziness

Seizure

Dementia

Others:

Allergy:

Seasonal

Angioedema

Pruritus

Others:

Food:

Environment:

Drug:

Date

MM slash DD slash YYYY

ASSESSMENT FOR FOLLOW-UP VISIT (SOAP NOTES)

Patient Name:

Date

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

PHYSICAL EXAMINATION

Gen:

AAO x 3

NAD

Head:

Normocephalic

Atraumatic

Neck:

Supple

No LAD

No JVD

No TM

Carotid Bruit

Eyes:

PERRLA

Clear Conjunctiva

Nose:

No Lesions

Clear

Rhinorrhea

Sinus Tenderness

Mouth:

No Lesions

Moist Mucosa

Clear Pharynx

CVS:

RRR

No Murmur/S3/S4

Palpable, NB Peripheral Pulses

Reproductive CP on Palp/Breaths/Arm Mvmt

Pulm:

CTA

Normal Effort

Wheezes

Rhonchi

Crackles/Rales

ABD:

Soft

NT/ND

No Organomegaly

Neuro:

CN II-XIII Intact

NL Motor Sensory

Tremors

NL Cerebellar

Vertigo

Hemiplegia:

Dominant Side:

Skin:

No Rash/Lesions

Erythema

Papules

Macules

Ecchymosis

Xerosis

Benign Lesions

MSK/Back:

Normal

Weak

Scarring

Rigidity/Stiffness

Unsteady Gait/Balance

Joint Pain

Limited ROM

Joint Swelling

EXT:

No C/C/E

(Edema) Scale (1–4):

Edema:

Cyanosis:

Clubbing:

Mental:

Oriented to Time, Person, Place

Disoriented

Is Pt. on Dialysis?

Fistula

Graft

Frequency

Is Pt. on G-tube?

Fistula

Graft

Frequency

COGNITIVE ASSESSMENT

Patient has difficulties with:

None

Learning

Memory Loss

Perception

Problem-solving

Patient has been diagnosed with/showing signs of:

None

Amnesia

Dementia

Alzheimer’s

Delirium

Last visit with Neurologist:

Last visit with Psychiatrist:

Patient agrees to a cognitive impairment assessment visit:

Yes

DIAGNOSIS(ES)

PLAN / MANAGEMENT

Others:

HTN Patient:

Has patient received a new Blood Pressure Monitor (BPM) since last visit?

Ensured patient’s BPM is calibrated and educated / trained patient on proper use.

Patient has defective / no BPM

Yes

Completed

Not Completed

Body Chart Details

Assessed by:

Date

MM slash DD slash YYYY

Description of wound

Wound Treatment

ADDENDUM / ADDITIONAL INFORMATION

Patient Name:

Date

MM slash DD slash YYYY

Age

Date of Birth:

MM slash DD slash YYYY

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Male

Female

Patient is medically stable

Yes

Patient requires immediate medical attention

Yes

Patient’s health in general:

Poor

Fair

Good

Very Good

Excellent

DOES PATIENT CURRENTLY HAVE OR HAD EXPERIENCED SYMPTOMS OF COVID-19, OR HAD COME IN CONTACT WITH AN INDIVIDUAL THAT IS SUSPECTED OR CONFIRMED TO HAVE COVID-19 WITHIN THE LAST 14 DAYS?
If YES, please ask if patient has been tested for COVID-19. If not, please order a COVID-19 test in the REFERRAL & ORDERS page.

Untitled

YES

Date

MM slash DD slash YYYY

FACE-TO-FACE ENCOUNTER

Patient Name:

Date

MM slash DD slash YYYY

Age

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

Home Health:

NO HOME HEALTH REFERRAL

(reasons):

Patient is in need of skilled services on an intermittent basis

Yes

Patient is homebound (as defined by Medicare)

Yes

The encounter with this patient was in whole, or in part, for the following medical condition(s)—which is the primary reason for home health care (list and specify all diagnoses that need to be treated/addressed via Home Health Care):

Based on the clinical findings contained within these notes, the following services are medically necessary:

Skilled Nursing

Cardiac / CHF Care

COPD Care

Diabetic Care

Foley Catheter Care

G.T. Care

Medical Management

Ostomy Care

Stroke Care

Wound Care (pressure sores/surgical wound)

Physical Therapy

Strengthening / Balance

Orthopedic Care

Home Health Aide

IV Therapy

MSW

Occupational Therapy

Speech Therapy

Others:

The skilled and other medically necessary services above are required due to the patient being/having:

Untitled

Requires an assistive device to ambulate

Poor ambulation — prone to falls

Post-op weakness

Debilitating dyspnea on exertion

Difficult and taxing effort to leave home

Untitled

Unable to leave home without maximum assistance and/or effort

Unable to ambulate

Unsteady gait with assistive device

Unable to negotiate stairs

Requires the assistance of 1-2 people to ambulate

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Medical restrictions (e.g. open, draining wound; leg elevated at all times, etc.)

Debilitating dizziness

Confusion / disorientation

Compromised mental status

Impaired ability or unsafe to drive

Others:

Additional Information:

Gen:

Change in Appetite | Weight change:

Loss

Gain

Night sweats

F/C

Fatigue

Date

MM slash DD slash YYYY

DR.

REFERRAL & ORDERS FORM

ORDER DATE:

MM slash DD slash YYYY

Patient Name:

Date of Service:

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

Home Health

for the following reasons:

Skilled Nursing

Physical Therapy

IV Therapy

Occupational Therapy

Speech Therapy

MSW

Home Health Aide

Others:

Referrals Outside Home Health

Cardiologist

Dietitian

Dermatologist

Endocrinology

ENT

Nephrologist

Neurologist

Ophthalmologist

Pain Management

Podiatrist

Psychiatrist

Wound Care Specialist

Others:

DME

Cane

Hospital Bed

Walker

Walker w/ Seat

Mattress

Glucometer

Diabetic Lancets/Strips

Wheelchair

Shower Chair

BP Machine

Incontinence Supplies

Others:

LABS & DIAGNOSTIC TESTS

CBC

CMP

Lipid Panel

HbA1c

Urinalysis C&S

TSH, T3 & T4

Renal Panel

Liver Function

EKG

Vitamin D

Iron

Ferritin

B12

Folate

PT/INR

X-Ray

Echocardiogram

CT Scan

Other:

Location:

Reason:

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With Contrast

No contrast

Reason:

Date

MM slash DD slash YYYY

DR.

DIABETES HEAD-TO-TOE EXAMINATION REPORT

Patient Name:

Date

MM slash DD slash YYYY

Diabetes:

Type 1

Type 2

Pre-diabetes

HbA1c Goal

< 6 months

≥ 6 months

Unknown

Duration of Diabetes in years:

Dietary Counseling:

Yes

Type of Diet:

Results of Last Finger-stick Blood Glucose Reading Per patient:

mg/dL

Patient has no glucometer for monitoring

Patient reports under control:

Yes

Current Diabetes Therapy:

Diet Control

Insulin

Oral Hypoglycemic

None

Medications

Other Meds:

OTC Meds

None

Other

List if any

Herbal Meds

None

Other

List if any

Pharmacist Last Reviewed Meds On:

MM slash DD slash YYYY

Reports side effects to meds:

Yes

If Yes Describe:

Reports Hyperglycemic Events

Yes

If Yes Describe:

Does Patient Know Their Current:

HbA1c?

Yes

Are goal levels met?

Yes

LDL?

Yes

Are goal levels met?

Yes

BP?

Yes

Are goal levels met?

Yes

Home Glucose Monitoring

Once a day

Twice a day

3-4 times a day

Other:

if on insulin, list current dose:

List dosing time:

Kidney, Heart & Vascular

Risk factors in addition to diabetes:

Blood Pressure

Goal:

Measured:

Date

MM slash DD slash YYYY

Triglycerides

Goal:

Measured:

Date

MM slash DD slash YYYY

Total (LDL & HDL)

Smoking status;

Never

Former

Current

Willing to Quit

Labs and Dx

Urine Albumin-to-Creantinine Ratio

Results

Date

MM slash DD slash YYYY

Serum Creatinine

Results

Date

MM slash DD slash YYYY

Estimated GFR

Results

Date

MM slash DD slash YYYY

Potassium

Results

Date

MM slash DD slash YYYY

Hemoglobin

Results

Date

MM slash DD slash YYYY

History of:

No History

Myocardial infarction

Heart failure

Stroke/TIA

Cardiovascular testing

Neurological testing

Nephrological testing

Dialysis/Kidney transplant

FEET

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LIMITED PE DUE TO TELEHEALTH VISIT

Current ulcer or history of foot ulcers:

YES

Foot Exam: Skin, Hair, and Nails Condition

Is the skin thin, fragile, shiny, and hairless?

YES

Are the nails thick, too long, ingrown, or infected with Fungal Disease?

YES

Muscular Deformities:

Bunions/Hallux Valgus

Charcot Foot

Foot Drop

Prominent Metatarsal

Heads

Toe Deformities

No deformities

Risk Categorization (check appropriate box):

Posterior Tibial

Low Risk Patient (all of the ff:)

Intact protective sensation

Pedal pulses present

No deformities

No prior foot ulcers

No amputation

Dorsalis Pedis

High Risk Patient (one or more):

Loss of protective sensation

Absent pedal pulses

Foot deformity

History of foot ulcer

Prior amputation

EYES

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Deferred

Visual Acuity (best corrected)

Intraocular Pressure

Dilated Fundus Exam Performed

Diagnosis

No Diabetic Retinopathy

YES

Non-Proliferative Diabetic Retinopathy

YES

Proliferative Diabetic Retinopathy

YES

Clinically Significant Macular Edema

YES

Plan:

Monitor only

Additional Testing / Treatment Recommended

Repeat Dilated Fundus Exam in months

MOUTH

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Deferred

Intraoral / Extraoral Caries:

YES

Periodontal Abscesses:

YES

Gingivitis:

YES

Periodontitis:

YES

Functional Concerns:

(e.g. eating, swallowing, etc.)

Periodontal Health in general:

Examination Findings:

Xerostomia

Fungal Infection

Parotid Gland Changes

Additional Testing / Treatment Recommended:

Refer to Specialist:

Re-evaluate in:

(months)

PLAN AND MANAGEMENT AS DISCUSSED WITH THE PATIENT

SMOKING AND TOBACCO-USE CESSATION CONSULTATION

Patient Name:

Date:

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

NON-SMOKER

SMOKER

OTHER TOBACCO USER

PATIENT’S READINESS TO QUIT:

Patient is ready to quit

Patient is thinking about quitting

Repetition relapse

Patient is not ready to quit

Counselling using 5Rs:

Target quit date:

• Relevance

(Why quitting is relevant)

• Risks

(Identify negative consequences of smoking or tobacco-use)

• Rewards

(Identify benefits of stopping)

• Roadblocks

(Identify barriers to quitting)

• Repetition

(Discuss that people often make repeated quit attempts before they become successful)

SMOKING HISTORY

# of Cigarettes/Day

# of Packs/Day

# of Years

# of Quit Attempts

Household Members

# of Smokers

# of Non-smokers

# of Children

SYMPTOMS

Abnormal Sputum

Asthma

Cough

Dyspnea

Hemoptysis:

Wheezing:

Withdrawal Symptoms

Mood Changes

Anxiety

Depression

Describe other, if any:

Others:

PLAN AND MANAGEMENT:

MEDICATIONS

Nicotine Replacement Therapy:

Patch

Gum

Inhaler

Nasal Spray

Lozenge

Bupropion SR

Tablets (starts 7 to 10 days before the target quit date)

Others:

ARRANGE FOLLOW-UP

Check back with the patient on the next visit

Date

MM slash DD slash YYYY

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NOT REQUIRED

NOT ASSESSED

INCOMPLETE

ADVANCE CARE PLANNING (ACP)

Patient Name:

Date:

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

I understand that the Federal Patient Self-Determination Act of 1990 requires that I be made aware of my right to make Healthcare Decisions for myself. I understand that I may express my wishes in various documents so that my wishes may be known when I am unable to speak for myself or make decisions on my own.

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I refuse to discuss / I wish to defer to future visits.

I have thought about what medical treatments I would want in the event I am unable to speak for myself, and have discussed it with my family, friends, caregivers, and/or medical practitioners.

I have thought about Physician Orders for Life-Sustaining Treatment (POLST).

This plan reflects my wishes and details my goals for my treatment and care.

I, completed an Advance Directive. A copy can be obtained from:

have not

have

Name:

Relationship:

Phone Number:

I, completed a living will. A copy can be obtained from:

have not

have

Name:

Relationship:

Phone Number:

I, completed a health care proxy, health care power of attorney, or otherwise nominated/elected/appointed a person to make healthcare decisions on my behalf. A copy can be obtained from:

have not

have

Name:

Relationship:

Phone Number:

I would like these goals/specific wishes/requests to be achieved/to come true:

My fears or worries about my future medical condition and care are:

When I am dying, where practicable, I would prefer to be cared for at:

My usual home

A family member’s home

A hospice or palliative care unit

In a hospital

Preferred not to answer

Others:

When I am dying, where practicable, I would like the following treatments: Palliative care

Palliative care

Stop medications which do not add to my comfort

Stop medical interventions which do not add to my comfort

Complementary & alternative therapies

Attend to my spiritual needs

Attend to my spiritual needs:

I would like the following life-sustaining measures, if practicable:

Cardiopulmonary resuscitation (CPR)

No life-sustaining actions to be taken

Intravenous fluids

Intubation & ventilation

Artificial feeding

Antibiotics

Blood transfusion & blood products

Preferred not to answer

I have the following requests to be carried out after I die: Organ/Body donation

Organ/Body donation

No service

Cremation

Procession / Freeze-drying

Church service ceremony

Burial

Preferred not to answer

PATIENT OR AUTHORIZED PERSON’S SIGNATURE:

Date

MM slash DD slash YYYY

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NOT REQUIRED

NOT ASSESSED

INCOMPLETE

ANNUAL WELLNESS VISIT (AWV)

Patient Name:

Date:

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

Patient regularly:

None

Smokes/Uses Tobacco

Drinks Alcohol

Uses Recreational Drugs

Patient’s health limits their social activity:

Not at all

Slightly

Moderately

Quite a bit

Extremely

Patient frequently experiences:

None

Sadness

Anxiety

High Stress Levels

Irritability

Patient considers their diet to be:

Healthy

Unhealthy

High-sodium

High-fat

High-sugar

ADLs patient is able to do on their own:

Dressing

Bathing

Toileting

Walking

Eating

None

IADLs patient is able to do on their own:

Shopping

Finances

Housekeeping

Medication Mgmt.

Meal Prep.

None

Patient sleeps:

< 6 hours

6 – 8 hours

≥ 9 hours per night

Patient experiences sexual problems:

Seldom

Sometimes

Often

Always

Refused

Patient takes their medication:

Always as prescribed

Sometimes as prescribed

Seldom as prescribed

Patient considers their weight as:

Underweight

Average

Overweight

Patient exercises for ≥ 20 minutes:

Daily

Several times a week

Few times a week

Patient sees their general health as:

Excellent

Very Good

Good

Fair

Poor

FUNCTIONAL ABILITY ASSESSMENT

Untitled

Patient is independent in all ADLs

Patient needs help with:

Untitled

Bathing

Toileting

Hygiene

Dressing

Grooming

Housekeeping

Eating/Feeding self

Meal Preparation

Medication Management

Stairs

Transferring

Shopping

Untitled

Patient requires assistance with Ambulation/Mobility

Patient has Bladder or Bowel Incontinence

Patient’s health in general:

Poor

Fair

Good

Very Good

Excellent

SAFETY

Patient uses an assistive device

Yes

specify if yes:

Cane

Walker

Crutches

Wheelchair

Bedbound

Patient uses an assistive device

Yes

Obstacles making ambulation difficult for patient:

Yes

None

specify if yes:

Stairs

Clutter

Slippery surfaces

Patient has assistance in home

Yes

None

Who:

Frequency:

Concerns or evidence of elderly abuse present

Yes

None

If yes, describe:

Patient is a fall risk

Yes

if yes, indicate number of fall episodes patient had in the last year::

indicate injuries sustained:

None

Injuries:

Untitled

Patient suffers from hearing loss

Yes

specify if yes:

Patient uses hearing aid(s)

No hearing aid(s)

Patient suffers from poor vision

Yes

specify if yes:

Patient uses glasses

No glasses

COGNITIVE ASSESSMENT

Patient has difficulties with:

None

Learning

Memory Loss

Perception

Problem-solving

Patient has been diagnosed with/showing signs of:

None

Amnesia

Dementia

Alzheimer’s

Delirium

Last visit with Neurologist:

Last visit with Psychiatrist:

ANNUAL WELLNESS VISIT (AWV)

Patient Name:

Date:

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

DEPRESSION SCREENING

Mark each question with the appropriate number. When completed, see recommendation based on total score.

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

Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Feeling tired or having little energy

Poor appetite or overeating

Trouble falling asleep, staying asleep, or sleeping too much

Feeling bad about yourself or feeling that you are a failure or that you have let yourself or your loved ones/family down

7) Trouble concentrating on activities, tasks, or things—such as reading or watching TV

Moving or speaking so slowly that other people have noticed; or being fidgety, restless, or moving a lot more than usual

Thoughts of hurting yourself or that you would be better off dead

TOTAL:

0	No Depression	10 – 14	Moderate Depression (suggest referral for mental health)
1 – 4	Minimal Depression	15 – 21	Moderate to Severe Depression (recommend referral for mental health)
5 – 9	Mild Depression

MEDICAL AND SOCIAL HISTORY

Gen:

Change in Appetite | Weight change:

Loss

Gain

Night sweats

F/C

Fatigue

Family History:

None

HTN

CAD

Heart Attack

HLD

Stroke

Others:

Medical History:

None

HTN

CAD

Heart Attack

HLD

Stroke

Others:

Surgical History:

(Include hospital stays, operations, etc.)

Social History: If yes, how often?

Uses or smokes tobacco

Yes

Daily

Several times a week

Few times a week

Social

Consumes alcohol

Yes

Daily

Several times a week

Few times a week

Social

Uses recreational drugs

Yes

Daily

Several times a week

Few times a week

Social

Last Colonoscopy:

Last ECG:

Last Mammography:

MEDICATION LIST

See Medication Reconciliation^*

^*If patient uses opioids, discuss if they have tried or are willing to try non-opioid pain therapies.

VITALS

Height

ft.

in.

Weight

lbs

BMI

Temp

°F

mmHg

bpm

O₂ Sat

ANNUAL WELLNESS VISIT (AWV)

Patient Name:

Date:

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

REVIEW OF SYSTEMS

Gen:

Change in Appetite

Weight change

Loss

Gain

Night sweats

F/C

Fatigue

Eyes:

Vision Change

Blurry

Double:

Eye pain:

D/C:

ENT:

Sore throat

Sinus Pain

Hearing loss:

Tinnitus:

Ear Pain:

Pulm: SOB:

At rest

On Exertion

Cough

Hemoptysis

Wheezing

OSA

CV:

Palpitations

Orthopnea

Arrhythmia

CAD

CABG

Syncope

Aneurysm

GI:

N/V

Abdominal pain

D/C

GERD

PUD

IBS

Colitis

Melena

Hematemesis

Hematochezia

Diarrhea

Constipation

Bowel Incontincence

Last LBM:

GU:

Dysuria

Hematuria

Frequency

Urgency

Nephropathy

Renal Failure

Renal Stones

Urine Incontinence

Stress Incontinence

Urge Incontinence

Mixed Incontinence

Functional Incontinence

MSK:

Back Pain

LBP

Radiating to LE

Stiffness

Myalgia

Others:

Pain:

Location:

Description:

Frequency:

Intensity (1 – 10):

Tx:

Intensity After Tx:

Endo:

Thyroidism:

Hypo

Hyper

Others;

Neuro:

Numbness

H/A

Dizziness

Seizure

Dementia

Others;

Allergy:

Seasonal

Angioedema

Pruritus

Others;

Food:

Environment:

Drug:

PHYSICAL EXAMINATION

Gen:

AAO x 3

NAD

Head:

Normocephalic

Atraumatic

Neck:

Supple

No LAD

No TM

Carotid Bruit

Eyes:

PERRLA

Clear Conjunctiva

Nose:

No Lesions

Clear

Rhinorrhea

Sinus Tenderness

Mouth:

No Lesions

Moist Mucosa

Clear Pharynx

CVS:

RRR

No Murmur/S3/S4

Palpable, NB Peripheral Pulses

Reproductive CP on Palp/Breaths/Arm Mvmt

Pulm:

CTA

Normal Effort

Wheezes

Rhonchi

Crackles/Rales

ABD:

Soft

NT/ND

No Organomegaly

EXT:

No C/C/E

Edema:

Edema: Scale (1–4):

Cyanosis:

Clubbing:

Skin:

No Rash/Lesions

Erythema

Papules

Macules

Ecchymosis

Xerosis

Benign Lesions

MSK/Back:

Normal

Scarring

Unsteady Gait/Balance

Limited ROM

Weak

Rigidity/Stiffness

Joint Pain

Joint Swelling

Neuro:

CN II-XIII Intact

DTR

NL Cerebellar

NL Motor Sensory

Tremors

Vertigo

Hemiplegia:

Dominant Side:

Mental:

Oriented to Time, Person, Place

Disoriented

ASSESSMENT / DIAGNOSIS(ES)

Primary:

2nd:

3rd:

4th:

PLAN / MANAGEMENT

Others:

ANNUAL WELLNESS VISIT (AWV)

Patient Name:

Date:

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex:

Male

Female

Patient is medically stable

YES

Patient requires immediate medical attention

YES

RECOMMENDED SCREENING SCHEDULE

1. Advise patient to continue with regular physical examination visits. 2. Advise patient to continue with all visits with specialists and discuss frequency as necessary. 3. Recommend any additional regular screening appointments/services as deemed necessary here:

REFERRALS AND ORDERS

Referrals and Orders for medical care and treatments have been completed:

YES

Advise patient that additional referrals to preventive, education, and counseling services are available for applicable community-based lifestyle interventions such as*:

Fall Prevention
Nutrition
Physical Activity
Tobacco-use Cessation
Weight Loss
Cognition

*Add to Referrals and Orders if patient requests for any.

ADVANCE CARE PLANNING (ACP)

Advance Care Planning has been completed:

YES

If no, please educate patient about what ACP is and discuss the benefits of having an ACP completed, as well as what additional documents the patient has the right to complete—such as an Advance Directive, Living Will, and Health Care Power of Attorney.

CURRENT MEDICAL PROVIDERS

Medical Provider:

PCP

Cardiologist

Dermatologist

OB/GYN

Oncologist

Psychiatrist

Name:

Others:

Date

MM slash DD slash YYYY

NOT REQUIRED

INITIAL PREVENTIVE PHYSICAL EXAMINATION (IPPE)

Patient Name:

Date:

MM slash DD slash YYYY

Age:

Date of Birth:

MM slash DD slash YYYY

Sex;

Male

Female

FUNCTIONAL ABILITY ASSESSMENT

Untitled

Patient is independent in all ADLs

Patient needs help with:

Untitled

Bathing

Toileting

Hygiene

Dressing

Grooming

Housekeeping

Eating/Feeding self

Meal Preparation

Medication Management

Stairs

Transferring

Shopping

Untitled

Patient requires assistance with Ambulation/Mobility

Patient has Bladder or Bowel Incontinence

Patient’s health in general:

Poor

Fair

Good

Very Good

Excellent

SAFETY

Patient has difficulties ambulating within home

Yes

specify if yes:

Cane

Walker

Crutches

Wheelchair

Bedbound

Patient uses an assistive device

Yes

Obstacles making ambulation difficult for patient:

Yes

None

specify if yes:

Stairs

Clutter

Slippery surfaces

Patient has assistance in home

Yes

None

Who:

Frequency:

Concerns or evidence of elderly abuse present

Yes

Patient is a fall risk

Yes

if yes, indicate number of fall episodes patient had in the last year::

indicate injuries sustained:

None

Injuries:

Others:

Patient suffers from hearing loss

Yes

Untitled

Patient uses hearing aid(s)

No hearing aid(s)

Patient suffers from hearing loss

Yes

Untitled

Patient uses glasses

No glasses

DEPRESSION SCREENING

Mark each question with the appropriate number. When completed, see recommendation based on total score.

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

Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Feeling tired or having little energy

Poor appetite or overeating

Trouble falling asleep, staying asleep, or sleeping too much

Feeling bad about yourself or feeling that you are a failure or that you have let yourself or your loved ones/family down

Trouble concentrating on activities, tasks, or things—such as reading or watching TV

Moving or speaking so slowly that other people have noticed; or being fidgety, restless, or moving a lot more than usual

Thoughts of hurting yourself or that you would be better off dead

TOTAL:

0 No Depression

1 – 4 Minimal Depression

5 – 9 Mild Depression

INITIAL PREVENTIVE PHYSICAL EXAMINATION (IPPE)

Patient Name:

Date:
MM slash DD slash YYYY

Age:

Date of Birth:
MM slash DD slash YYYY

Sex:
Male
Female

MEDICAL AND SOCIAL HISTORY

Family History:
None
HTN
CAD
Heart Attack
DM
HLD
CA
Stroke

Others;

Medical History:
None
HTN
CAD
Heart Attack
DM
HLD
CA
Stroke

Others;

Surgical History:
(Include hospital stays, operations, etc.)

MEDICATION LIST

See Medication Reconciliation^*
^*If patient uses opioids, discuss if they have tried or are willing to try non-opioid pain therapies.

Social History: If yes, how often?

Uses or smokes tobacco
No
Yes
Daily
Several times a week
Few times a week
Social

Consumes alcohol:
No
Yes
Daily
Several times a week
Few times a week
Social

Uses recreational drugs:
No
Yes
Daily
Several times a week
Few times a week
Social

Patient exercises:
No
Yes
Several times a week
Few times a week

Patient’s diet:
Healthy
Unhealthy
High-Sodium
High-fat
High-sugar

Last Colonoscopy:

Last ECG:

Last Mammography:

VITALS

Height

ft.

in.

Weight

lbs

BMI

Temp

°F

BP mmHg

HR bpm

O2 Sat %

REVIEW OF SYSTEMS

Gen:
Change in Appetite
Weight change
Loss
Gain
Night sweats
F/C
Fatigue

Eyes:
Vision Change
Blurry

Double:
L
R

Eye pain:
L
R

D/C:
L
R

ENT:
Sore throat
Sinus Pain

Hearing loss:
L
R

Tinnitus:
L
R

Ear Pain:
L
R

Pulm:
SOB
At rest
On Exertion
Cough
Hemoptysis
Wheezing
OSA

CV:
CP
Palpitations
Orthopnea
Arrhythmia
CAD
CABG
Syncope
Aneurysm

GI:
N/V
Abdominal pain
D/C
GERD
PUD
IBS
Colitis
Melena
Hematemesis
Hematochezia

Last LBM:

GU:
Dysuria
Hematuria
Frequency
Urgency
Nephropathy
Renal Failure
Renal Stones

MSK:
Back Pain
LBP
Radiating to LE
Stiffness
Myalgia

Pain:

Location:

Description:

Frequency:

Intensity (1 – 10):

Tx:

Intensity After Tx:

Endo:
Thyroidism:
Hypo
Hyper
DM

Neuro:
Numbness
H/A
Dizziness
Seizure
Dementia

Allergy:
Seasonal
Angioedema
Pruritus

Food:

Environment:

Drug:

INITIAL PREVENTIVE PHYSICAL EXAMINATION (IPPE)

Patient Name:

Date
MM slash DD slash YYYY

Age:

Date of Birth:
MM slash DD slash YYYY

Sex:
Male
Female

PHYSICAL EXAMINATION

Limited PE due to Telehealth Visit

Other PE Findings:

Gen:
AAO x 3
NAD

Head:
Normocephalic
Atraumatic

Neck:
Supple
No LAD
No JVD
No TM
Carotid Bruit

Eyes:
PERRLA
Clear Conjunctiva

Nose:
No Lesions
Clear
Rhinorrhea
Sinus Tenderness

Mouth:
No Lesions
Moist Mucosa
Clear Pharynx

CVS:
RRR
No Murmur/S3/S4
Palpable, NB Peripheral Pulses
Reproductive CP on Palp/Breaths/Arm Mvmt

Pulm:
CTA
Normal Effort
Wheezes
Rhonchi
Crackles/Rales

ABD:
Soft
NT/ND
BS
No Organomegaly

EXT:
No C/C/E

Edema:
L
R

Edema: Scale (1–4):

Cyanosis:
LE
UE
L
R

Clubbing:
LE
UE
L
R

Skin:
No Rash/Lesions
Erythema
Papules
Macules
Ecchymosis
Xerosis
Benign Lesions

MSK/Back:
Normal
Scarring
Unsteady Gait/Balance
Limited ROM
Weak
Rigidity/Stiffness
Joint Pain
Joint Swelling

Neuro:
CN II-XIII Intact
DTR
NL Cerebellar
NL Motor Sensory
Tremors
Vertigo

Hemiplegia:
L
R

Dominant Side:
L
R

Mental:
Oriented to Time, Person, Place
Disoriented

ASSESSMENT / DIAGNOSIS(ES)

Primary:

2nd:

3rd:

4th:

PLAN / MANAGEMENT:

Others:

Patient is medically stable:
YES
NO

Patient requires immediate medical attention
YES
NO

REFERRALS AND ORDERS

Referrals and Orders for medical care and treatments have been completed:
YES
NO

Advise patient that additional referrals to preventive, education, and counseling services are available for applicable community-based lifestyle interventions such as*:

• Fall Prevention	• Physical Activity	• Weight Loss
• Nutrition	• Tobacco-use Cessation	• Cognition

*Add to Referrals and Orders if patient requests for any.

ADVANCE CARE PLANNING (ACP)

Advance Care Planning has been completed:
YES
NO

Date
MM slash DD slash YYYY

GIMG (Initial Chart)

ROUTE SHEET

PATIENT REGISTRATION FORM

PATIENT INFORMATION

INSURANCE INFORMATION

EMERGENCY CONTACT

RECENT MEDICAL VISITS / SERVICES

RECORDS RELEASE AUTHORIZATION

CONSENT FOR TREATMENT, ACKNOWLEDGMENT OF HIPAA NOTICE, AND DISCLOSURE OF PHI

CONSENT

HIPAA NOTICE / NOTICE OF PRIVACY PRACTICES

DISCLOSURE OF PHI FOR PAYMENT

SMOKING AND TOBACCO-USE CESSATION CONSULTATION

SMOKING HISTORY

Household Members

MEDICATIONS

ADVANCE CARE PLANNING (ACP)

ANNUAL WELLNESS VISIT (AWV)

FUNCTIONAL ABILITY ASSESSMENT

SAFETY

COGNITIVE ASSESSMENT

ANNUAL WELLNESS VISIT (AWV)

DEPRESSION SCREENING

MEDICAL AND SOCIAL HISTORY

MEDICATION LIST

VITALS

ANNUAL WELLNESS VISIT (AWV)

REVIEW OF SYSTEMS

PHYSICAL EXAMINATION

ASSESSMENT / DIAGNOSIS(ES)

ANNUAL WELLNESS VISIT (AWV)

RECOMMENDED SCREENING SCHEDULE

REFERRALS AND ORDERS

ADVANCE CARE PLANNING (ACP)

CURRENT MEDICAL PROVIDERS

INITIAL PREVENTIVE PHYSICAL EXAMINATION (IPPE)

FUNCTIONAL ABILITY ASSESSMENT

SAFETY

DEPRESSION SCREENING

INITIAL PREVENTIVE PHYSICAL EXAMINATION (IPPE)

MEDICAL AND SOCIAL HISTORY

MEDICATION LIST

VITALS

REVIEW OF SYSTEMS

INITIAL PREVENTIVE PHYSICAL EXAMINATION (IPPE)

PHYSICAL EXAMINATION

ASSESSMENT / DIAGNOSIS(ES)

REFERRALS AND ORDERS

ADVANCE CARE PLANNING (ACP)

CONSENT FOR TREATMENT, ACKNOWLEDGMENT
OF HIPAA NOTICE, AND DISCLOSURE OF PHI