Patient Name:________________________  DOB:_______________  Date: _______________________

 

Medications List (1159F and 1160F)

 

Name of Medicine

Dose

How medication is taken (1 daily, PRN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADVANCED DIRECTIVES (1157F or 1158F)

Do you have a living will or advanced directive?                                 □   Yes                                   □   No

Do you have a DNR (Do Not Resuscitate)?                                             □   Yes                                   □   No

Do you have a durable power of attorney for healthcare?             □   Yes                                   □   No

If no to the above questions, are you open to discussion

with your provider?                                                                                         □   Yes                                   □   No

 

PREVENTATIVE CARE

When was the last time you had:

Preventative Care

In the last year

In the last 2-4 years

In the last 5 years

In the last 10 years

Never

Not applicable

Pneumonia Vaccine (4040F)

 

 

 

 

 

 

Shingles Vaccine

 

 

 

 

 

 

Breast Cancer Screening

 

 

 

 

 

 

Colorectal Cancer Screening

 

 

 

 

 

 

Cervical Cancer Screening

 

 

 

 

 

 

Have you had a flu shot (G8482) this year?           □   Yes                                  □   No

 

 

ACTIVITIES OF DAILY LIVING/FUNCTIONAL

  1. Do you have difficulties walking?

No                                                                 □

Sometimes                                                  □

Yes, often                                                     □

Not applicable, I cannot walk                  □

 

  1. Can you get to places not in walking distance without help?

*For example, can you travel alone by bus, taxi, or drive your own car?

Yes        

No         

 

 

 

  1. Can you shop for groceries or clothes without help?

Yes        

No         

 

 

 

  1. Can you prepare your own meals?

Yes        

No         

 

 

  1. Can you do your own housework without help?

Yes        

No         

 

  1. Can you handle your own money without help?

Yes        

No         

  1. Do you need help eating, bathing, dressing, or getting around your home?

Yes        

No         

 

COGNITIVE SKILLS (1170F)

  1. Are you having difficulties driving your car?

No                                                             □

Sometimes                                              □

Yes, often                                                 □

Not applicable, I do not use a car          

 

  1. Have you been given any information to help you keep track of your medications?

Yes        

No         

  1. How often do you have trouble taking medicines the way you have been told to take them?

I do not have to take medicine                  

I always take them as prescribed              

Sometimes I take them as prescribed                                                                                                       

I seldom take them as prescribed             

 

  1. How often in the past 4 weeks, have you had problems using the telephone?

Never               □

Seldom            □

 

Sometimes    □

Often               □

Always             □

 

  1. During the past 4 weeks, was someone available to help you if you needed and wanted help? *For example, if you felt very nervous, lonely or blue, got sick and had to stay in bed, needed someone to talk to, needed help with daily chores, or needed help just taking care of yourself.

Yes, as much as I wanted     

Yes, quite a bit                          

Yes, some                                

Yes, a little                               

No, not at all                            

 

NUTRITION

  1. How often in the past 4 weeks, have you had trouble eating well?

Never                                                                  

Seldom                                                                

Sometimes                                                        

Often                                                                   

Always                                                                 

 

SAFETY

  1. Have you been given any information to help you identify hazards in your house that might hurt you?

Yes

No

 

  1. Do you always fasten your seatbelt when you are in a car?

Yes, Usually                                                       

Yes, Sometimes                                               

No                                                                         

 

 

 

 

PAIN ASSESSMENT

  1. During the past 4 weeks, how much bodily pain have you generally had?

No pain (1126F)                                               

Very mild pain (1125F)                                  

Mild pain (1125F)                                            

Moderate pain (1125F)                                 

Severe pain (1125F)                                        

 

  1. On a scale of 0-10, with 0 being no pain and 10 being the worst pain experience, what is your pain scale?

_____________________________

 

WELLNESS

  1. During the past 4 weeks, how would you rate your general health?

Excellent                                                             

Very good                                                          

Good                                                                    

Fair                                                                        

Poor                                                                     

 

  1. Are you a smoker? (1034F)

No (1036F)                                                         

Yes, and I might quit                                      

Yes, but I am not ready to quit                   

 

  1. Did you have a drink containing alcohol in the past year?

 Yes       

 No        

 

  1. How have things been going for you in the past 4 weeks?

Very well – could hardly be better           

Pretty good                                                       

Good and bad are about equal                  

Pretty bad                                                          

Very bad – could hardly be worse            

 

 

  1. How confident are you that you can control and manage most of your health problems?

Very confident                                                 

Somewhat confident                                     

Not very confident                                         

I do not have any health problems           

 

 

DEPRESSION SCREENING (G044)

  1. Over the past 2 weeks, have you experienced having little interest or pleasure in doing things?

Yes        

No         

 

  1. Over the past 2 weeks, have you been feeling down, depressed or hopeless?

Yes        

No         

 

FALLS ASSESSMENT

  1. Have you fallen two (2) or more times in the past year?

Yes         (1101F)

No          (1100F)

  1. Were you injured in any falls in the past year?

Yes        

No         

 

BLADDER CONTROL (1090F)

  1. Do you experience urinary incontinence?

Yes        

No         

 

PHYSICAL ACTIVITY (1103F)

  1. Do you exercise regularly?

Yes, daily                     

Yes, > 3x week            

Yes, < 3x week            

No                                

 

  1. During the past 4 weeks, what was the hardest physical activity you could do for at least 2 minutes?

 Very heavy                                                  

Heavy                                                                  

Moderate                                                          

Light                                                                     

Very light                                                            

 

SOCIAL DETERMINANTS OF HEALTH

  1. Do you find that sometimes you must choose between buying groceries or medications?

Yes        

No         

 

  1. Think about the place you live. Do you have problems with any of the following? CHOOSE ALL THAT APPLY

  Pests such as bugs, ants, or mice

 Mold

  Lead paint or pipes              

Lack of heat             

Oven or stove not working

Smoke detectors missing or not working

Water leaks

None of the above

 

  1. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?

Yes                                

No                                 

Already shut off          

 

 

 

May 2021 Notes from the Network

May 2021 Notes from the Network

Opportunity to Meet CEO Dr. John Pagan: PA Clinical Network CEO, John Pagan MD FACS, will be conducting three townhall style meetings on Tuesday May 11. This is an opportunity for our membership to meet and ask questions of our new CEO. Three virtual options will be...

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