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2. Annual Wellness Questionnaire
First Name. Last Name.
MM/DD/YYYY
including date, illnesses, hospital, operations, allergies, injuries, and treatments:
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(how much, how often per week): ___ (tobacco include cigarettes, chew, snuff, pipes, cigars, vapor cigarettes) -------------------------------------------------------------------------------------------------------------
Medicare doesn't cover routine hearing exams, hearing aids, or exams for fitting hearing aids. Medicare coverage for hearing rehabilitation services, including a comprehensive audiology assessment to determine if a hearing aid is appropriate. Coinsurance/deductible apply. --------------------------------------------------------------------------------------------------------------------
. . . . .PREVENTIVE SERVICES - Screening for Sexually Transmitted Infections (STIs) and Counseling to Prevent STIs. For screening for chlamydia, gonorrhea, and syphilis in women at increased risk for STIs who are not pregnant report V74.5 and V69.8. For screening for syphilis in men at increased risk, report V74.5 and V69.8. Additional DX V22.0, V22.1, or V23.9 if pt pregnant. Coinsurance/deductible waived on counseling. Office visit coinsurance/deductible apply. --------------------------------------------------------------------------------------------------------------------
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PREVENTIVE SERVICES - Glaucoma eye screening. Coinsurance/deductible apply. Factors at-risk if have 1) diabetes mellitus; 2) a family history of glaucoma; 3) are African-Americans aged 50 and older; 4) Are Hispanic-Americans aged 65 and older. --------------------------------------------------------------------------------------------------------------------
Date and Result normal/abnormal. --------------------------------------------------------------------------------------------------------------------
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MMM/YYYY. Result normal/abnormal. --------------------------------------------------------------------------------------------------------------------
MMM/YYYY. result. type test. 4 test Option: Fecal occult blood test/Flexible Sigmoidoscopy/ Colonoscopy/Cologuard. --------------------------------------------------------------------------------------------------------------
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. . . . 20 minutes 3 or more days a week. . . . The Benefits of Physical Activity: 1) Control your weight. 2)Reduce your risk of cardiovascular disease. 3) Reduce your risk for type 2 diabetes and metabolic syndrome. 4) Reduce your risk of some cancers. 5) Strengthen your bones and muscles. 6) Improve your mental health and mood. 7) Improve your ability to do daily activities and prevent falls, if you're an older adult. 8) Increase your chances of living longer. --------------------------------------------------------------------------------------------------------------------
. . . . Benefit: 1) Healthy eating helps prevent high cholesterol and high blood pressure and helps reduce the risk of developing chronic diseases such as cardiovascular disease, heart disease, cancer, stroke, and diabetes. 2) Healthy eating helps reduce one's risk for developing obesity, osteoporosis, iron deficiency, and dental caries - cavities. 3) Eat healthy food (as fresh fruits, fish and vegetables). Unhealthy food. ie fried foods, sweets and "junk food". --------------------------------------------------------------------------------------------------------------------
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. --------------------------------------------------------------------------------------------------------------------
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? --------------------------------------------------------------------------------------------------------------------
Have you ever needed treatment for a mental health disorder such as depression, anxiety disorder, bipolar disorder or psychosis? --------------------------------------------------------------------------------------------------------------------
Home Safety and few recommendation to avoid falls. 1) Assess home for raised doorway thresholds. 2) Remove clutter, loose carpet, unsecured floor coverings. 3) Always maintain a clean dry floor. 4) No electrical cords in walk ways. 5) Maintenance of assistive devices. 6) Handrails in hallways. 7) Install grab bars in the bathroom. 8) Use non-skid mats inside and outside of shower/tub/toilet. 9) Use of appropriate bathing aides/chair. 10) Store household items on lower shelves so that you can access them easily. 11) Use reaching devices to access things that are higher than you can reach. 12) Wear low heeled, comfortable shoes that fit well. 13) Have night lights installed. 14) Keep home well lit. 15) Always make sure to sit up on the edge of the bed and get use to light before attempting to walk. 16) Smoke detectors at home. 17) Carbon monoxide detector. --------------------------------------------------------------------------------------------------------------------
. . . . Gait (walking characteristics / abnormality): A normal gait is characterized by the Pt walking with head erect, arms swinging freely at the side, and striding without hesitant. This gait scores 0. With a weak gait (score as 10), the Pt is stooped but is able to lift the head while walking without losing balance. Steps are short and the Pt may shuffle. With an impaired gait (score 20), the Pt may have difficulty rising from the chair, attempting to get up by pushing on the arms of the chair/or by bouncing (i.e., by using several attempts to rise). The Pt's head is down, and he or she watches the ground. Because the Pt's balance is poor, the Pt grasps onto the furniture, a support person, or a walking aid for support and cannot walk without this assistance. A limp is also considered a walking abnormality. A limp may be permanent or temporary. --------------------------------------------------------------------------------------------------------------------
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. . . .IV means Intravenous therapy / saline lock (infusion of liquid substances directly into a vein): --------------------------------------------------------------------------------------------------------------------
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Mental status (Pt's own assessment of ability to walk): "Are you able to go the bathroom alone or do you need assistance?" If the Pt's reply judging his or her own ability is consistent with the ambulatory order on the Kardex®, the Pt is rated as "normal" and scored 0. If the Pt's response is not consistent with the nursing orders or if the Pt's response is unrealistic, then the Pt is considered to overestimate his or her own abilities and to be forgetful of limitations and scored as 15. --------------------------------------------------------------------------------------------------------------------
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* Required field