"Medicare Patient Health Risk Assessment (HRA) & History Form - Sccipa" - Santa Clara County, California

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Medicare Patient Health Risk Assessment (HRA) & History
1. To be completed by patient during visit.
nd
2. Provider must review and sign in the space provided on bottom of 2
page.
Provider: _________________________________
Health Plan: ____________________________
Name:
Date of Birth:
Today’s Date:
Gender:
Age:
Primary Language:
A. Medical History: Please indicate which of the following medical issues you’ve had with approximate dates.
Condition
Year
Condition
Year
Other Conditions
Year
___Congestive Heart Failure
___Cancer
1.
___Heart Attack
___Diabetes
2.
___Stroke
___Thyroid Problem
3.
___High Blood Pressure
___COPD
4.
___Depression
___High Cholesterol
5.
___Chronic Kidney Disease
___Arthritis
6.
B. Social History: Please answer questions 1-10 regarding your social habits.
•If so, what type of exercise and how frequent? ___________________________
(1) Do you exercise regularly? Yes No
(2) What best describes your home environment? Private home
Assisted living
Other: ___________________________
(3) If at a private home, do you depend on a spouse/family member for assistance? Yes No •If so, who? _______________
•If so, how many packs/day? _________ •How many years? _________
(4) Do you smoke? Yes No
•If so, how many drinks/month? ____________
(5) Do you drink alcoholic beverages? Yes No
•If so, how often? ________________
•Type? __________________
(6) Do you take recreational drugs? Yes No
(7) Do you eat a balanced diet? Yes No
(8) Do you have issues with your sexual health? Yes No
Good Fair Poor (10) Have you leaked any amount of urine in the last 3 months? Yes No
(9) Rate your general health?
C. Family History: Please indicate if you have a blood related relative with any of the following medical issues.
Condition
Relationship
Condition
Relationship
Other/Relationship:
__Heart Disease
__Cancer
1.
__Stroke
__Diabetes
2.
__High Cholesterol
__Glaucoma
3.
__High Blood Pressure
__Alcoholism
4.
__Depression/suicide
__Asthma/COPD
5.
D. Hospitalization/Surgery History: Please indicate your hospitalization and surgery history.
Event
Date
Event
Date
1.
4.
2.
5.
3.
6.
E. Patient’s medical provider/supplier list: List other physicians/suppliers who provided you care in the past year.
Name
Date
Condition reviewed/
Name
Date
Condition reviewed/
treated
treated
1.
4.
2.
5.
3.
6.
Provider only (sign & date): ____________________________
Office Staff only: _____________
2
Page 1 of
Medicare Patient Health Risk Assessment (HRA) & History
1. To be completed by patient during visit.
nd
2. Provider must review and sign in the space provided on bottom of 2
page.
Provider: _________________________________
Health Plan: ____________________________
Name:
Date of Birth:
Today’s Date:
Gender:
Age:
Primary Language:
A. Medical History: Please indicate which of the following medical issues you’ve had with approximate dates.
Condition
Year
Condition
Year
Other Conditions
Year
___Congestive Heart Failure
___Cancer
1.
___Heart Attack
___Diabetes
2.
___Stroke
___Thyroid Problem
3.
___High Blood Pressure
___COPD
4.
___Depression
___High Cholesterol
5.
___Chronic Kidney Disease
___Arthritis
6.
B. Social History: Please answer questions 1-10 regarding your social habits.
•If so, what type of exercise and how frequent? ___________________________
(1) Do you exercise regularly? Yes No
(2) What best describes your home environment? Private home
Assisted living
Other: ___________________________
(3) If at a private home, do you depend on a spouse/family member for assistance? Yes No •If so, who? _______________
•If so, how many packs/day? _________ •How many years? _________
(4) Do you smoke? Yes No
•If so, how many drinks/month? ____________
(5) Do you drink alcoholic beverages? Yes No
•If so, how often? ________________
•Type? __________________
(6) Do you take recreational drugs? Yes No
(7) Do you eat a balanced diet? Yes No
(8) Do you have issues with your sexual health? Yes No
Good Fair Poor (10) Have you leaked any amount of urine in the last 3 months? Yes No
(9) Rate your general health?
C. Family History: Please indicate if you have a blood related relative with any of the following medical issues.
Condition
Relationship
Condition
Relationship
Other/Relationship:
__Heart Disease
__Cancer
1.
__Stroke
__Diabetes
2.
__High Cholesterol
__Glaucoma
3.
__High Blood Pressure
__Alcoholism
4.
__Depression/suicide
__Asthma/COPD
5.
D. Hospitalization/Surgery History: Please indicate your hospitalization and surgery history.
Event
Date
Event
Date
1.
4.
2.
5.
3.
6.
E. Patient’s medical provider/supplier list: List other physicians/suppliers who provided you care in the past year.
Name
Date
Condition reviewed/
Name
Date
Condition reviewed/
treated
treated
1.
4.
2.
5.
3.
6.
Provider only (sign & date): ____________________________
Office Staff only: _____________
2
Page 1 of
Medicare Patient Health Risk Assessment (HRA) & History
Name:
Date of Birth:
F. Current Medications/Supplements: List all current prescription and non-prescription medicines, vitamins, herbs, etc.
Name
Date last
Name
Date last
filled
filled
1.
6.
2.
7.
3.
8.
4.
9
5.
10.
Medication allergies: _____________________________________________________________
Other allergies: __________________________________________________________________
G. Functional Ability/Safety Screening
1. Do you feel unsteady when you walk?
Yes
No
2. Have you recently fallen?
Yes
No
3. Do you need help with eating, getting dressed, grooming, bathing, walking or using the toilet?
Yes
No
4. Does your home have rugs in the hallways, grab bars in the bathrooms, hand-rails on the stairs,
Yes
No
proper lighting, smoke and carbon monoxide detectors?
5. Do you need help with the phone, transportation, shopping, preparing meals, house-work, laundry,
Yes
No
medications or managing money?
6. Have you noticed vision impairment?
Yes
No
H. Depression Screening Questionnaire: Over the last 2 weeks, how often have you been bothered by any of the
following problems?
Not at all
Several
More than
Nearly
(0 points)
days
half the days
every day
(1 point)
(2 points)
(3 points)
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
3. Trouble falling or staying asleep, or sleeping too much.
4. Feeling tired or having little energy.
5. Poor appetite or overeating.
6. Feeling bad about yourself—or that you are a failure or have let
yourself or your family down.
7. Trouble concentrating on things, such as reading the newspaper or
watching television.
8. Moving or speaking so slowly that other people could have noticed.
Or the opposite—being so fidgety or restless that you have been
moving around a lot more than usual.
9. Thoughts that you would be better off dead, or of hurting yourself in
some way.
10. If you checked off any problems, how difficult have these problems
made it for you to do your work, take care of things at home, or get
along with other people?
*Healthcare professional will evaluate answers for the questionnaire.
_________________________________
Patient (sign & date):
Provider only (sign & date): ____________________________
Office Staff only: _____________
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