MEDICARE PREVENTIVE WELLNESS VISIT INITIAL AND SUBSEQUENT MPE (welcome to Medicare visit) G0402 V70.0 AWV Initial (Annual Wellness Visit) G0438 V70.0 MEDICAL/SOCIAL HISTORY As cited in EMR □ Past Personal Illnesses or Injuries: Injury or Illness Date Hospitalized □ per EMR Drug Allergies □ Tobacco Use: per EMR □ □ Medications, Supplements and Vitamins per EMR Alcohol Use: per EMR □ □ Social History Notes (including diet and physical activities ) per EMR Drug Use: per EMR □ Family History: per EMR DEPRESSION SCREEN □ □ 1. Over the past two weeks, have you felt down, depressed or hopeless? Yes No □ □ 2. Over the past two weeks, have you felt little interest or pleasure in doing things? Yes No FUNCTIONAL ABILITY/SAFETY SCREEN □ □ 1. Was the or longer than 30 seconds? Yes No patient’s timed Up & Go * test unsteady □ □ 2. Does the patient need help with the phone, transportation, shopping preparing meals, housework Yes No laundry, medications, or managing money? □ □ 3. Does the patients home have rugs in the hallway, lack grab bar in the bathroom, lack handrails on the stairs Yes No or have poor lighting? to any of the questions regarding depression or function/safety should trigger further evaluation. A “yes” response *Stand up from a chair and walk a distance of about 10 feet turn around and walk back and sit down in the chair using normal footwear and any assistance devices. □ FINDINGS per EMR Height: Weight: Blood Pressure: BMI: Visual Acuity: L R: Hearing evaluation: □ Current Physician/Provider: per EMR Name____________________ MRN#___________________ DOB:_________________ page 2
MEDICARE PREVENTIVE WELLNESS VISIT INITIAL AND SUBSEQUENT MEDICAL/SOCIAL HISTORY □ As cited in EMR Past Personal Illnesses or Injuries: Injury or Illness Date Hospitalized Medications, Supplements and Vitamins □ per EMR Social History Notes (including diet and physical activities ) □ per EMR Family History: □ per EMR Drug Allergies □ per EMR Tobacco Use: □ per EMR Alcohol Use: □ per EMR Drug Use: □ per EMR MPE (welcome to Medicare visit) G0402 V70.0 AWV Initial (Annual Wellness Visit) G0438 V70.0 DEPRESSION SCREEN 1. Over the past two weeks, have you felt down, depressed or hopeless? □ Yes □ No 2. Over the past two weeks, have you felt little interest or pleasure in doing things? □ Yes □ No FUNCTIONAL ABILITY/SAFETY SCREEN 1. Was the patient’s timed Up & Go * test unsteady or longer than 30 seconds? □ Yes □ No 2. Does the patient need help with the phone, transportation, shopping preparing meals, housework □ Yes □ No laundry, medications, or managing money? 3. Does the patients home have rugs in the hallway, lack grab bar in the bathroom, lack handrails on the stairs □ Yes □ No or have poor lighting? A “yes” response to any of the questions regarding depression or function/safety should trigger further evaluation. *Stand up from a chair and walk a distance of about 10 feet turn around and walk back and sit down in the chair using normal footwear and any assistance devices. FINDINGS □ per EMR Height: Weight: Blood Pressure: BMI: Visual Acuity: L R: Hearing evaluation: Current Physician/Provider: □ per EMR Name____________________ MRN#___________________ DOB:_________________ page 2
family_practice_medicare_form_2.docx