brevaMedicare Annual Wellness Visit, initial
Encounter
Patient name: [ ] Date of birth: [ ] Date and time of encounter: [ ] Clinician: [ ]
Before the visit
Eligibility and prior wellness visits checked, with source and date: [ ] Health risk assessment completed, by whom and date: [ ]
History
Medical and surgical history: [ ] Family history: [ ] Current medications and supplements: [ ] Current opioid prescriptions reviewed: [ ] Substance use screening tool and result: [ ] Current providers and suppliers involved in care: [ ]
Measurements
Height, weight, body mass index and blood pressure, with units: [ ] Other measurements taken: [ ]
Screening and safety
Cognitive assessment method and findings: [ ] Depression screening tool and result: [ ] Hearing, daily activities, fall risk and home safety findings: [ ]
Prevention plan
Written screening schedule for the next 5 to 10 years: [ ] Risk factors and conditions, with interventions recommended or underway: [ ] Personalized health advice and referrals: [ ]
Optional elements
Advance care planning discussed, if the patient agreed: [ ] Physical activity and nutrition assessment tool and result, if performed: [ ]
Other care today
Problems addressed separately today, if any: [ ]
Follow-up
Follow-up timing and purpose: [ ] Return precautions discussed: [ ] Patient questions and understanding: [ ]