Medicare Annual Wellness Visit printable pdf download

Medicare Annual Wellness Visit

LOAR, HEBLE, AND KNIGHT FAMILY PHYSICIANS

MICHAEL G. LOAR MD

BETH POEPPELMAN PA-C

THERESA A. HEBLE MD

MARY CAIN, PA-C

JOHN W. KNIGHT DO

7780 S. Broadway, Suite 150, Littleton CO 80122 Phone: 303-795-5980 Fax: 303-795-7881

MEDICARE IPPE and ANNUAL WELLNESS VISIT PATIENT

QUESTIONNAIRE

Your Medicare Annual Wellness Visit is a consultation with your provider during which

the information on this form will be reviewed, a mini mental status exam will be

performed, and a health plan will be discussed. Lab work and physical exams are not

performed at this appointment. Your provider will discuss any labs or exams they would

like to have performed at a follow-up appointment. The providers prefer to do the labs

and exams at the second appointment in the event that additional testing may be needed.

*Please complete this form and bring it with you to your appointment. *

Appointment Date:_________/Time_________ Provider: ___________

Patient name: ____________________________

Date of Birth: _____________

Please provide a list of all your present medications. Include over the

Counter medications, such as vitamins and herbal supplements. Also

include medications that you may take only intermittently.

Name of Medication

Dose (Strength)

Frequency

Dose

Frequency

Name of Non-prescription

Medication

Are you on CPAP? Y / N

Setting:

Are you on Oxygen? Y / N

Nocturnal liter

Continuous liter

flow per

Flow per minute:

minute:

Medicare Annual Wellness Visit