Patient Assessment Form 2019/2020

Patient Name:

Date of Birth:

Date of Visit:

Last Visit:

Provider: Welton, Laurie A.

INFLUENZA VACCINATION

Have you had you 2019/2020 Flu season vaccination?

Yes No

If yes: Where?

If yes: When?

if No, would you like your flu vaccine today?

Yes No

PHEUMONIA VACCINATION (65 OR OLDER)

Have you had a Pneumococcal vaccination in the past?

Yes No

If so, when?

Are you interested in receiving a Pneumococcal Vaccination?

Yes No

Weight Assessment

Current weight:

Normal Overweight Underweight

Would you like help with nutritional counseling at today's visit

Yes No

If no, why?

Pt Declined

CURRENT MEDICATIONS

Since your last, have there been any changes to any medications that you take including prescription, over the counter, herbals and

Yes No

TOBACCO SCREENING

Do you use tobacco products?

Yes No

Please pu a check

Cigarettes

Vaping

Cigars

Chew

Hookah

Other

HEPATITIS C SCREENING

Were you born between 1945 to 1965?

Yes No

Do you receive a blood transfusion prior to 1992?

Yes No

Do you have a history of injection drug user?

Yes No

If yes to any of the questions above, would you like to be screened?

Yes No

PROVIDER ONLY: B20 Patients. VL Suppression

Documented VL less than 20 copies/ml

Documentation of VL equal to greater than 200 copies/ml

VL not perfomed

Medical Visit Frequency (Check one)

Patient had atleast one medical visit in each 6 month period of the 24 month measurement period with a with a minimum of 60 days between medical visits. Patient did not have at least one medical visit in each 6 months of the 24 month measurement period with a minimum of 60 days between visits. Did the patient have a diagnosis of psoriasis, psoriasis arthritis or rheumatoid arthritis? Documentation of negative or managed position TB screen with further evidence that TB is not active within one year of patient visit No documentation of negative or manage positive TB screen

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