Your Wellness Visit Guide

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Caring for Seniors

Annual Wellness Visit Provider Toolkit

Prepare for your Annual Wellness Visit or Welcome to Medicare Visit. Let’s make the most of your appointment.

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It’s one of the most valuable benefits of your health coverage.

Many people have questions about this important appointment. That’s why this doctor approved guide was created.

On these pages, you’ll find answers to frequently asked questions about the Wellness Visit. You’ll also find the health questions your doctor or other health provider will ask you. This information will help you prepare ahead of time so your visit can be as productive as possible.

Allow yourself time to review your guide. Fill it out and carefully consider all of the questions. As you do,

put together a list of all the doctors and other health providers you see, any recent hospital visits you’ve had and the medications you take.

Completing your guide will give your doctor an overview of your current health to focus on the topics that matter most to your wellness. The completed guide can also ensure that you’re getting the care you need right now and help your doctor develop a personal prevention plan that’s right for you.

Remember: Your Wellness Visit is not your physical exam. It’s an annual consultation specifically for your doctor to stay up-to-date with you and your medical needs.

Congratulations on scheduling your Annual Wellness Visit or Welcome to Medicare Visit!

Prepare to make the most of your one-on-one with your doctor

How to use this guide:

1 Tear off the first two pages and keep them for your records.

2 Read this guide, carefully consider the questions and fill them out.

3 Take the completed guide to your visit and give it to your medical team at the beginning of your appointment.

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1 How often do I get a covered Wellness Visit?

Your Annual Wellness Visit is covered fully every calendar year. And your Welcome to Medicare Visit is fully covered if you have it within 12 months of Medicare Part B eligibility.

2 What’s the difference between an Annual Wellness Visit and a Welcome to Medicare Visit?

Your Annual Wellness Visit happens every year to make sure you and your medical team have a chance to review and plan for your better health throughout the year. Your Welcome to Medicare Visit happens only once when you first enroll in Medicare and gives you and your doctor a chance to go over your health as a starting point for your care under your new Medicare plan. To have your Welcome to Medicare Visit covered, you need to make it within the first 12 months of your Medicare Part B eligibility.

3 I see my doctor regularly and keep up with my yearly physical exams. Why do I need a Wellness Visit?

While most office visits are about treatment, your Wellness Visit is about prevention. It’s not a physical exam. It’s a one-on-one discussion with your doctor to review your health from all angles, physical and emotional. At the visit, you and your doctor will create a personal wellness plan based on your unique health factors, including:

• Medical and family health history

• Medication list

• Potential health issues

• Health-screening schedule

• Lifestyle and health and wellness goals

Some questions you might have about your Wellness Visit

4 What about other items I may want to discuss with my doctor, or what if I need additional tests or treatment?

Your Wellness Visit is offered to you at no charge. However, the rules about which services are provided during these visits are very specific. The purpose for this visit is to review your overall health and discuss prevention and wellness. If you need additional services (like lab tests or medical treatments), your usual deductible (if applicable), copayment or coinsurance may apply.

5 Will I be charged a copay for this visit?

Your Wellness Visit is covered in full by your Medicare Advantage plan, with a $0 copay. However, during this visit, your doctor may find that it’s necessary to provide other types of medical care that are not covered in this visit. If that happens, your doctor will bill separately for those services. Some of these services, like receiving care for a medical condition or ordering lab tests, will require your normal cost-sharing.

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Your Wellness Visit GuideFill it out. Take it with you.

Last Name:

First Name:

Date of Birth: Today’s Date:

For each question, select the answer that best describes you.

General Health:How would you rate your general health?

1 Overall health

Excellent Very good Good Fair Poor

2 Physical health (compared to last year)

Much better Slightly better Same Slightly worse Much worse

3 Eyesight (compared to last year)

Same Slightly worse Much worse

4 Hearing (compared to last year)

Same Slightly worse Much worse

5 Emotional/mental health (compared to last year)

Much better Slightly better Same Slightly worse Much worse

6 Pain: In the past 7 days, how much pain have you experienced?

None Some A lot

If you answered “Some” or “A lot,” please rate the severity of your pain on a scale of 1 to 10. (1 being the least severe pain and 10 being the most intense pain; circle one)

1 2 3 4 5 6 7 8 9 10

7 Weight: In the past 6 months, have you lost or gained 10 pounds without trying?

Yes No

To Be Completed By Your Health Provider

Height: _________________ Weight: _________________ BMI: _____________________

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Emotional/Mental Health:During the past month:

1 Have you often felt down, depressed or hopeless? Yes No

2 Have you often had little interest or pleasure in doing things? Yes No

3 Have you felt nervous, anxious or on edge? Yes No

Broken Bones/Falls:Have you:

1 Broken a bone? Yes No

2 Had a bone mineral density test? Yes No

3 Fallen within the past year? Yes No

4 If you have fallen within the past year, how many times?

Bladder/Bowel:

1 In the past six months, have you accidentally leaked urine? Yes No

2 Do you have problems with loss of bowel control? Yes No

Immunizations:

1 Have you had a flu vaccination within the past year? Yes No

2 Have you had a pneumonia shot? Yes No

3 Have you had a shingles vaccination? Yes No

4 When was your last tetanus/diphtheria shot? Date:

Home Safety:

1 Do you have trouble with the stairs inside or outside your home? Yes No

2 Do you have hazards inside the home such as a lack of grip bars in the bathtub, loose rugs or poor lighting? Yes No

3 Does your home have working smoke alarms? Yes No

4 Does your home have a carbon monoxide monitor? Yes No

Your Name: DOB: Date:

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Preventive Screenings:Have you had any of the following screenings?

1 Breast cancer (women only) Yes No Date:

2 Prostate cancer (men only) Yes No Date:

3 Colon cancer Yes No Date:

4 Cholesterol Yes No Date:

5 Glaucoma eye exam Yes No Date:

Nutrition:In the past 7 days:

1 How many servings of fruits and vegetables did you typically eat each day? serving(s)/day

2 How many servings of high-fiber foods or whole grains did you typically eat each day? serving(s)/day

3 How many servings of fried or high-fat foods did you typically eat each day? serving(s)/day

4 How many sugar-sweetened beverages did you typically consume each day? serving(s)/day

Medications:

1 Do you understand why you’re prescribed your medications? Yes No

2 Are you taking your medications as directed by your doctor? Yes No

3 Do you experience any side effects from your medications? Yes No

If yes, what are they?

From which drug(s)?

4 Are you concerned about the cost of your medications? Yes No

5 In addition to prescription medications, are you taking any over-the-counter supplements? Yes No

If yes, what are they?

6 Do you ever forget to take your medications? Yes No

Your Name: DOB: Date:

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Lifestyle Choices:

1 Do you currently smoke or use other tobacco products? Yes No

2 Have you smoked or used other tobacco products in the past? Yes No

If yes, have you stopped? When?

3 Do you drink alcohol? Yes No

If yes, how many drinks per week?

4 Do you drive? Yes No

5 Do you use seat belts? Yes No

6 Describe your level of exercise or physical activity:

Activities of Daily Living:Can you:

1 Get out of bed by yourself? Yes No

2 Dress yourself? Yes No

3 Make your own meals? Yes No

4 Do your own shopping? Yes No

5 Bathe yourself? Yes No

6 Do your laundry/housekeeping? Yes No

7 Manage your money, pay your bills and track your expenses? Yes No

Your Name: DOB: Date:

List of Health Providers:Please list any doctors or other health providers you have seen over the past year and the medical problems that were/are being treated.

DOCTOR/HEALTH PROVIDER NAME:

SPECIALTY: REASON:

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Hospitalizations and Emergency Room Visits in the Past Year:

DATE OF VISIT: REASON:

Your Name: DOB: Date:

Advance Directives:

1 Have you decided who would speak for you and make health care treatment choices for you if you became ill and could not make them for yourself? Yes No

2 If you answered “yes” to the question above, have you spoken to that person about your choices? Yes No

3 Have you completed a written advance directive (that is, a living will and/or health care power of attorney)? Yes No

Social Support:Do you have someone who helps you manage your health care, like a friend or family member? If yes, please provide their contact information.

Health Contact Name:

Street Address:

City State Zip Code

Telephone (with area code)

Your Name: DOB: Date:

Great job!You’ve completed your guide. Now take it with you to your appointment.

Thank you for filling out this guide. You should feel good about being proactive! Following through with preventive care is one of the best things you can do for your well-being.

Your health is important. Highmark, your doctor and your other health providers are here to help protect it with the resources, information and personal support you need.

Be sure to bring this completed guide to get the most from your Wellness Visit.

Reminder:Take all medications with you to your Wellness Visit. This includes:

Prescription drugs

Drugs that you purchase over the counter

All vitamins and supplements

Substances that you place on your body, such as ointments or patches

For Office Use Only

Physician Signature: Date:

Please place a copy of this assessment in the patient’s chart or medical record.

MM-159 (R4-15)