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): ______

______

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 Name ______Dr. Signature ______Date: ______

Maximum / Score
5 / Orientation
  • 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

Total

Assess level of consciousness along a continuum

Alert Drowsy Stupor Coma