Medicare Patient Health Risk Assessment (Hra) & History

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Medicare Patient Health Risk Assessment (HRA) & History
1. To be completed by patient during visit.
nd
2. Provider must review and sign in the space provided on bottom of 2
page.
Provider: _________________________________
Health Plan: ____________________________
Name:
Date of Birth:
Today’s Date:
Gender:
Age:
Primary Language:
A. Medical History: Please indicate which of the following medical issues you’ve had with approximate dates.
Condition
Year
Condition
Year
Other Conditions
Year
___Congestive Heart Failure
___Cancer
1.
___Heart Attack
___Diabetes
2.
___Stroke
___Thyroid Problem
3.
___High Blood Pressure
___COPD
4.
___Depression
___High Cholesterol
5.
___Chronic Kidney Disease
___Arthritis
6.
B. Social History: Please answer questions 1-10 regarding your social habits.
•If so, what type of exercise and how frequent? ___________________________
(1) Do you exercise regularly? Yes No
(2) What best describes your home environment? Private home
Assisted living
Other: ___________________________
(3) If at a private home, do you depend on a spouse/family member for assistance? Yes No •If so, who? _______________
•If so, how many packs/day? _________ •How many years? _________
(4) Do you smoke? Yes No
•If so, how many drinks/month? ____________
(5) Do you drink alcoholic beverages? Yes No
•If so, how often? ________________
•Type? __________________
(6) Do you take recreational drugs? Yes No
(7) Do you eat a balanced diet? Yes No
(8) Do you have issues with your sexual health? Yes No
Good Fair Poor (10) Have you leaked any amount of urine in the last 3 months? Yes No
(9) Rate your general health?
C. Family History: Please indicate if you have a blood related relative with any of the following medical issues.
Condition
Relationship
Condition
Relationship
Other/Relationship:
__Heart Disease
__Cancer
1.
__Stroke
__Diabetes
2.
__High Cholesterol
__Glaucoma
3.
__High Blood Pressure
__Alcoholism
4.
__Depression/suicide
__Asthma/COPD
5.
D. Hospitalization/Surgery History: Please indicate your hospitalization and surgery history.
Event
Date
Event
Date
1.
4.
2.
5.
3.
6.
E. Patient’s medical provider/supplier list: List other physicians/suppliers who provided you care in the past year.
Name
Date
Condition reviewed/
Name
Date
Condition reviewed/
treated
treated
1.
4.
2.
5.
3.
6.
Provider only (sign & date): ____________________________
Office Staff only: _____________
2
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