Fillable Printable Blank Medicare Health Risk Assessment Form
Fillable Printable Blank Medicare Health Risk Assessment Form
Blank Medicare Health Risk Assessment Form
6/25/14 V.3
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MEDICARE(HEALTH(RISK(ASSESSMENT(
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Date of Exam:
MMDDYYYY!
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(((((((((Examiner(NPI:(
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! ! ! ! ! ! ! ! ! ! ! ! ! MD! DO!
Examiner Name:
Last!Name,!First!Name!
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Exam Start Time:
HH:MM
AM
PM
Exam End Time:
HH:MM
AM
PM
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Member Information
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Name:
Race/Ethnicity: ________________ Sex: ____
Language: __________________
DOB: / /
Address:
Home Phone:
Cell Phone:
HPM Member ID#:
Member’s PCP:
PCP’s Address:
Advanced Care Planning
Advanced
directive
Yes
No
Has health care proxy? Yes
No
Has living will? Yes
No
Allergies & Reported Reactions
No known drug
allergies
Known
drug
allergies
List of Allergies: ____________________
___________________________________
___________________________________
Reported reactions: ________________
__________________________________
__________________________________
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Family History
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Who lives in same household with applicant? (if none write “none” in space.)
Name
Age
Relationship
Remarks
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Examiner’s!Initial!__________! Page!2!
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Communication:
Difficulty reading
Unable to read
Interpreter
Difficulty hearing
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Family Medical History:
Condition
Father
Mother
Sibling
Alcohol
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Breast Cancer
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Other Cancer
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COPD
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Depression/Suicide
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Other Psychiatric Disorder
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Diabetes
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Heart Disease
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Stroke
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Glaucoma
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Blood Pressure
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Other
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Medications
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List medications currently taken (prescribed and OTC):
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Drug
Dose/Route
Frequency
Reason for Medication
_________________________________!
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List hospitalizations in the past 12 months: __________________________________________
_______________________________________________________________________________
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Examiner’s!Initial!__________! Page!3!
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Health Information
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Level of physical activity
Low
Moderate
High
In the past 12 months, did you
talk with a doctor or other health
provider about your level of
exercise or physical activity?
!!!!!!!!!!!!!!!!!Yes!
!!!!!!!!!!!!!!!!!!No!
!!!!!!!!!!!!!!!!!!I!had !n o !vis its !
!!!!!!!!!!!!!!!!!!In!the !p a s t!1 2!
!!!!!!!!!!!!!!!!!!months!
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In the past 12 months, did a
doctor or other health provider
advise you to start, increase or
maintain your level of exercise
or physical activity?
!!!!!!!!!!!!!!!!!Yes!
!!!!!!!!!!!!!!!!!!No!
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Do you use assistive devices?
!!!!!!!!!!!!!!!!!Cane!
!!!!!!!!!!!!!!!!!Wheel!chair!
!!!!!!!!!!!!!!!!!Crutches!
Hand grip strength?
Low
Moderate
High
Do you feel tired or exhausted?
Yes
No
Compared to other people your age, how would you describe your health?
Excellent
Good
Fair
Poor
Do you exercise?
Yes
No
Times per week? ______
Do you have generalized pain? Scale of 1-10, 10 is the highest 1 2 3 4 5 6 7 8 9 10
Site/Location: ____________________________________________________________________________
Duration
< 1 month
1-6 months
6-12 months
> 1 year
Type
Dull
Sharp
Constant
Intermittent
Aggrevates
Resting
Movement
Sleep
Relieves
Medicine
Rest
Heat
Cold
Therapy
Functional ADL Status:
Independent
Minimal Supervision
Needs Assistance
Totally Dependent
Assistive Device
Ambulation
Bathing
Dressing
Eating
Toileting
Transfers
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Examiner’s!Initial!__________! Page!4!
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IADL Status:
Independent
Minimal Supervision
Needs Assistance
Totally Dependent
Assistive Device
Med Management
Transportation
Money Management
Housework
Accessing Resources
HEENT:!
Yes
No
Cataracts?
❣
❣
Laser eye surgery?
❣
❣
Do you wear eye glasses?
❣
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Do you use a hearing aid?
❣
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Chest:!
Yes
No
Do you have asthma?
❣
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Do you have emphysema?
❣
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Do you have COPD?
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Have you had or do you have wheezing?
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Do you use home oxygen?
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Have you ever smoked tobacco products?
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Suicide/Homicidal Assessment:
❣ Suicidal thoughts
❣ Homicidal thoughts
❣ Denies suicidal/homicidal thoughts
Social History:
Tobacco Use:
Yes
No
Do you currently smoke tobacco products?
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How many packs per day did you / do you smoke?
❣ <1
❣ 1
❣ 2
❣ >2
At what age did you start?
At what age did you stop?
Offered smoking cessation?
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Respiration:
Yes
No
Do you cough every morning or nearly every morning?
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Are you short of breath at rest?
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Are you short of breath with exertion?
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Have you discussed you shortness of breath with your doctor?
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When?
MMDDYYYY!
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Spirometry?
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When?
MMDDYYYY!
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Examiner’s!Initial!__________! Page!5!
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Social(Support:(
Lives!alone!
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Lives!with!family/friends!
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Home/Physical!environment:!
Clean/organized!
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Cluttered!
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Stairs!
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Fall!risk!identified!
❣!
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Has!your!doctor!or!other!health!
provider!done!anything!to!help!
prevent!falls!or!treat!problems!with!
balance!or!walking?!
!!!!!!!!!!!!!!!!!Yes!
!!!!!!!!!!!!!!!!!!No!
!!!!!!!!!!!!!!!!!!I!had !n o !vis its !
!!!!!!!!!!!!!!!!!!In!the !p a s t!1 2!
!!!!!!!!!!!!!!!!!!months!
Cardiac:!
Yes
No
Have you had a heart attack?
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When?
MMDDYYYY!
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Do you have shortness of breath at night or when lying down?
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Do you have swelling in the legs?
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CHF?
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High blood pressure?
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Have you ever been diagnosed with heart failure?
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Other heart conditions?
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Vascular:!
Yes
No
Do you have pain in your calf muscle, on walking, that goes away with rest?
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Do you have to sit down or lean forward before the pain goes away?
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Peripheral Vascular disease?
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GI and Nutritional:!
Height
Ft.
In.
Weight
Lbs.
Self
Reported
Measured
BMI: _______________?
If BMI > 30, consider weight screening (BMI)
Yes
No
Weight loss?
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Voluntary?
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Amount? ______________
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Prescribed ensure?
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Intrafeeding/tube?
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Ostomy?
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Hematologic/lymphatic/infectious:
❣ Reviewed and negative
❣ Easy bruising
❣ Swollen lymph nodes
❣ Frequent infections
Other : _________________________________________
_______________________________________________
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❣ Reviewed and negative
❣ Anemia
❣ Iron deficiency ❣ B12 ❣ Due to kidney disease
❣ Due to chemotherapy
❣ Bleeding disorder
❣ Lymphedema
❣ Lymphoma ❣ Multiple myeloma
❣ Acute leukemia ❣ Chronic leukemia ❣ Thrombocytopenia
❣ HIV/AIDS ❣ MRSA
Other: _________________________________________
GU:!
Yes
No
Examiner’s!Initial!__________! Page!6!
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Do you lose control of urine?
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Do you have blood in your urine?
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Do you have trouble with erections?
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Kidney failure?
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Are you on dialysis?
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Is urine leakage a problem for you?
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Are you using absorbance?
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Ostomy?
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Have you received treatment for urine leakage?
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Neuropsychiatric:!
Yes
No
Do you have or have you had seizures?
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❣ Petit mal
❣ Grand mal
❣ Other
Date of last seizure
MMDDYYYY
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Do you get dizzy when standing?
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Have you fainted or lost consciousness?
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Have you had a stroke?
❣
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During the last year, have you fallen unexpectedly more than once or twice?
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Do you have a tremor, difficulty with you balance or trouble getting out of a chair?
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Do you have weakness in arms, legs or feet?
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Have you used drugs or alcohol in the past?
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Do you use drugs or alcohol now?
If yes, diagnose alcohol dependence
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Pain: ❣ Comprehensive pain assessment completed ❣ Member denies any pain
Location ________________________________________________________________________________________________________________
Pain Scale:
Now (0-10): __________
At best (0-10): __________
At worst (0-10): ________
Goal (0-10): __________
Location ________________________________________________________________________________________________________________
Pain Scale:
Now (0-10): __________
At best (0-10): __________
At worst (0-10): ________
Goal (0-10): __________
Relief level from meds or other modalities: No ❣ 25% ❣ 50% ❣ 75% ❣ 100% ❣
Pain affected functional ability: No ❣ Yes ❣ Pain affected quality of life: No ❣ Yes ❣ (Include frequency of pain in notes)
How has pain affected quality of life? _________________________________________________________________________________________
Notes: _________________________________________________________________________________________________________________
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Examiner’s!Initial!__________! Page!7!
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Depression Screen
Yes
No
Are you sad or depressed?
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If yes, ask the following questions
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Not all
Several
Days
More than
half of the
days
Nearly
every
day
Had little interest in or pleasure from doing things?
Felt down, depressed, or hopeless?
Had trouble falling asleep, staying asleep or slept too much?
Felt tired or had little energy?
Had a poor appetite or overeaten?
Felt bad about yourself, felt you were a failure or felt you had let yourself or your family down?
Had trouble concentrating on things like reading or watching television?
Thinking you would be better off dead or that you should hurt yourself in some way?
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Psychiatric:
❣ Reviewed and negative
❣ Depressed mood
❣ Anxiety
❣ Trouble sleeping
❣ Hallucinations
❣ Behavior problems
❣ Trouble with concentration
Other : _________________________________________
_______________________________________________
❣ Reviewed and negative
❣ Depression
❣ Recurrent ❣ Major depressive disorder
❣ Schizophrenia
❣ Bipolar disorder
❣ Personality disorder
❣ Paranoid disorder
Other: _________________________________________
_______________________________________________
Endocrine:!
Yes
No
Do you have diabetes? ❣ Type 1 ❣ Type 2
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❣
Insulin dependent?
❣
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Other meds or dietary restrictions: ______________________________________________
Was your LDL checked?
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When?
MMDDYYYY!
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Hemoglobin A1C test in past year?
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When?
MMDDYYYY!
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Do you have a glucometer?
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Three most recent blood sugars and dates?
When?
MMDDYYYY
When?
MMDDYYYY
When?
MMDDYYYY
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Examiner’s!Initial!__________! Page!8!
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HEMOTOLOGY/CANCER:
Have you been diagnosed with cancer?
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Primary: ❣ Breast
❣ Colon ❣ Lung
❣ Prostate ❣ Melanoma
❣ Brain
❣ Blood/leukemia Other:
______________________________
Is you cancer in remission?
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Has your cancer spread?
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Are you currently being treated for cancer?
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Treatment:
Chemotherapy
When?
MMDDYYYY
Radiation
When?
MMDDYYYY
Surgery
When?
MMDDYYYY
Have you had a mastectomy?
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Have you had a colectomy?
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Have you had a prostatectomy?
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Physical Exam
!
Blood!Pressure!reading:!
Temperature:!
Pulse:!
BMI:!
Weight:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Height:!
Other:!
Eyes:!
Present
Absent
Icterus
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Fundoscopy performed
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Neovascularity
❣
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Hemorrhages
❣
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Exudates
❣
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Macular edema
❣
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Microaneurysm(s)
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Chest:!
Respiratory rate
❣
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Labored respiration
❣
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Hyperexpansion
❣
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Wheezes
❣
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Rhonchi
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Rales
❣
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Prolonged E/I ratio
❣
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Examiner’s!Initial!__________! Page!9!
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Cardiovascular:!
Jugular venous distension
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Cardiomegaly
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Gallop
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Murmur
❣
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Peripheral edema
❣
❣
Pedal pulses
❣
❣
Abdomen:!
Ascites
❣
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Hepatomegaly
❣
❣
Bruit
❣
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Skin and Extremities:!
Breakdown/rashes/itchiness
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Bruising
❣
❣
Venous Stasis
❣
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Ulcer
❣
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Neurological:!
Present
Absent
Alertness
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Speech
❣
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Strength
❣
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Muscle mass
❣
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Monofilament sensation
❣
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Position Sense
❣
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Reflexes (ankle)
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Reflexes (knee)
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Flattened facies
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Festination
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Resting tremor, ridigity, bradykinesia
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Listing all appropriate diagnoses and indicate if chronic
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Have you discussed your chronic illnesses with your doctor?!
❣ Yes
❣ No
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When did you have that discussion?
MMDDYYYY
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Patients with chronic conditions should periodically discuss them with their doctor
Examiner’s!Initial!__________! Page!10!
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Encourage patient education regarding chronic disease and treatment including side effects
Encourage adherence to treatment regimens especially for chronic diseases like DM, HTN, and hyperlipidemia
Diagnoses previously recorded for the member:
Please checkmark EITHER the “chronic” box OR the “not currently treated/not confirmed” box BUT NOT BOTH. Mark
chronic if the condition is currently under treatment and/or signs/symptoms are present. Be sure to mark only the most
specific diagnosis among a group of related diagnoses.
#
Last occurrence Diagnosis
Chronic/Active
Not currently treated/
Not confirmed
Diagnostic Testing:!
Reported by Member
Dental Exam
When?
MMDDYYYY
Influenza Vaccine
When?
MMDDYYYY
Pneumococcal Vaccine
When?
MMDDYYYY
Eye Exam
When?
MMDDYYYY
Glaucoma Screening
When?
MMDDYYYY
Podiatry Exam (if diabetic)
When?
MMDDYYYY
Bone Density
When?
MMDDYYYY
If yes, DEXA ❣, Ultrasound ❣
Mammogram
When?
MMDDYYYY
Pap Smear
When?
MMDDYYYY
PSA
When?
MMDDYYYY
Examiner’s!Initial!__________! Page!11!
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Stool Guiac
When?
MMDDYYYY
Sigmoidoscopy
When?
MMDDYYYY
Colonoscopy
When?
MMDDYYYY
STD testing
When?
MMDDYYYY
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Reason for Referral
Refer!to!case!management?!!!!!!!!!!!❣ Yes ❣ No!
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I!un d er st an d !t h a t!th e !e va lu a tio n !d o ne!to d a y!is !fo r !th e !p u rp o s e !o f!d a ta !co lle c tio n .!!T h e !p h y sic ian !d oing !th is !evaluation!is!
not!assuming!responsibility!for!my!care!and!will!not!provide!direct!treatment!to!me.!!If!I!have!any!questions!regarding!
my!medical!care!or!treatment,!I!understand!that!I!should!contact!my!own!physician!with!those!questions!or!call!911!in!
the!case!of!a!medical!emergency.!
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I!wa s!e x amin ed !b y !D r .!_ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ !!!!!D a te :!!_ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _!
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Mr./Mrs.!__________________________________________________________________________________________!
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Signature:!_________________________________________________________________________________________!
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❣ Examiner, please check to confirm that member has been informed of the above statement.
Examiner’s Signature: ___________________________________________________________________________
