MEDICARE PERSONALIZED PREVENTION PLAN SERVICES ENCOUNTER FORM Page 1 of 3

MEDICARE PERSONALIZED PREVENTION PLAN SERVICES ENCOUNTER FORM – Page 1 of 3

Patient’s name: ______Date of Birth: ______Medical Record #: ______

Medicare’s B eligibility date: ______Date of Exam: ______Date of last exam: ______

MEDICAL/SOCIAL HISTORY Injury or illness Date Hospitalized?

Medications, supplements and Vitamins: ______Social history notes (including diet and physical activities): ______

In the past year, have you had more than 5 (for men) and 4 (for women) alcoholic drinks in a single day more than twice? ( ) Y ( ) N

Family History Notes: ______

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. Do you need help with phone/transportation/shopping/meals/housework/laundry/medications/money mgmt? ( ) Yes ( ) No

3. Does your home have rugs in the hallway, lack grab bars in bathroom, lack stair handrails, havepoor lighting? ( ) Yes ( ) No

4. Have you noticed any hearing difficulties? ( ) Yes ( ) No

Hearing Evaluation: ______

PHYSICAL EXAMINATION Height: ______Weight: ______Blood Pressure: ______BMI: ______Visual Acuity: L ______R ______

ELECTROCARDIOGRAM Referral or result: ______

EVALUATIONS/REFERRALS BASED ON HISTORY, EXAM AND SCREENING: ______

Past Surgeries ______Past Illnesses______OTHER PHYSICIANS (Name & Specialty): ______

______

Patient Signature & Date: Physician Signature:

PERSONALIZED PREVENTION PLAN SERVICES (MINI-MENTAL SCREENING) Page 2 of 3 Medical Record #: ______

Patient ______Dr. Signature ______Date: ______

Maximum Score Orientation 5  What is the current year Correct? ( )  What is the current season Correct? ( )  What is the current month Correct? ( )  What day of the week is today Correct? ( )  What is today’s date Correct? ( ) 5  Which town is this clinic in? Raleigh ( )  What country are you in currently? USA ( )  What street are you at currently? Six Forks/Spring Forest ( )  Which facility are you in currently? Dr. Chatterjee’s ( )  Which State are we in? North Caroline ( ) 3 Registration  Name 3 objects: Ball, Car, Man. Take 1 seconds to say each. Then ask the patient all three. Give 1 point for each correct answer. Repeat until the patient has learnt all three. Count trials and record: Trial: ______5 Attention and Calculation  Spell WORLD backwards 3 Recall  Ask for the 3 objects (Ball, Car, man). Give 1 point for each correct answer 2 Language  Show patient a Pen and ask to name the object  Show patient a watch and ask to name the object 1  Ask the patient to repeat the phrase “No ifs, and’s or buts.” 3  Ask the patient to take a paper, fold it in half and put it on the table (1 point for each step) 1  Give the patient a block to say “CLOSE YOUR EYES” and ask them to read and follow 1  Write a sentence

1  Copy the design shown

Assess level of consciousness along a continuum

Alert Drowsy Stupor Coma PERSONALIZED PREVENTION PLAN SERVICES ENCOUNTER FORM – Page 3 of 3 Medical Record #: ______

COUNSELING and REFERRAL OF OTHER PREVENTIVE SERVICES

Services Limitations (Applicable Only for Medicare) Recommendations Scheduled Vaccines No deductible/no co-pay • Pneumococcal Medium/high-risk factors: • Influenza • End-stage renal disease • Hepatitis B (if medium/high risk) • Patients with hemophilia who received Factor VIII/IX concentrates • Clients of institutions for the mentally retarded • Persons who live in the same house as a carrier of Hepatitis B virus • Homosexual men • Abusers of illicit injectable drugs Mammogram Pap and Pelvic exams Prostate cancer screening [Last done]  Digital Rectal Exam (DRE)  Prostate specific antigen (PSA) Colorectal cancer screening Exempt from Part B deductible • Fecal occult blood test • Flexible sigmoidoscopy • Screening colonoscopy • Barium enema Diabetes and self-management Requires referral by treating physician for patient training With diabetes or renal disease Bone bass measurements Requires diagnosis related to osteoporosis or Estrogen deficiency Glaucoma testing Medical nutrition therapy for Requires referral by treating physician for patient Diabetes or renal disease With diabetes or renal disease Cardiovascular screening blood tests Order as a panel if possible • Total cholesterol • High-density lipoproteins • Triglycerides Diabetes screening tests Patient must be diagnosed with one of the following: • Fasting blood sugar (FBS) or glucose . Hypertension tolerance test (GTT) . Dyslipidemia . Obesity (BMI >=30 kg/m2) . Previous ID of elevated impaired FBS or GTT .. or any two of the following: . Overweight (BMI >=25 but <30) . Family history of diabetes . Age 65 years or older . History of gestational diabetes or birth to baby weighing more than 9 pounds Abdominal aortic aneurysm screening Patient must be referred through IPPE and not have  Sonogram had a screening for abdominal aortic aneurysm before under Medicare. Limited to patients who meet one of the following criteria: • Men who are 65-75 years old and have smoked more than 100 cigarettes in their lifetime • Anyone with a family history of abdominal aortic aneurysm • Anyone recommended for screening by the U.S. Preventive Services Task Force Eye check (Last eye check: )

Physician’s signature: ______Date: ______