874362 Rev. 01/2020 © 2020 Cigna Form 360 Page 7 of 7
Anticonvulsants (Phenobarbital, Carbamazepine, Phenytoin,
Valproic acid):
Preventive Medicine: (Please Use "D" if patient declines, N/A,
"S" for scheduled, or "A" for advised)
Date Result:
Result:
Result:
Long Term Medication Monitoring (Annual) Reviewed *Patients
diagnosed with Diabetes:
*HbA1C:
*Microalbuminuria: Date
*Retinal Eye Exam: Date
*Name of Eye Care Provider:Opioid Evaluation:
Patients diagnosed with COPD:
Patients diagnosed with CHF and/or CAD:
Serum Drug Concentration:
NoYes
NoYes
Result:
ACE or ARB Prescribed:
Beta Blocker Prescribed:
LVEF Assessment Date:
Describe Other Referral Labs Diet Monitor Meds SELECT TREATMENT
PLAN DIAGNOSES
Please list any diagnoses, not already noted under current
conditions, which affect patient care, treatment or management.
COORDINATION OF CARE (Please list any providers/specialists
involved in the patient's care and any supplier of equipment):
PLAN:
None
HMR reviewed and updated on today's visit?
BEHAVIORAL HEALTH REFERRAL:
CASE MANAGEMENT REFERRAL:
No
Yes
NoYes
No
Yes
Care Coordination
If Yes, please specify:
Social Concerns Patient Education Other (specify):
Indication:
I discussed the following with my patient:
OTHER COMMENTS:
Patient Email (OPTIONAL)
Tobacco cessation and education
*Urinary incontinence *Physical Activity
*Fall risk prevention
Other (specify):
Diet Modification 90 Day Rx FillHigh Risk Medications
PA NP DO MD
DO MD
SUPERVISING PHYSICIAN NAME: (if applicable)
DATE:
SUPERVISING PHYSICIAN SIGNATURE: (if applicable)
DATE:
RENDERING SIGNATURE: RENDERING NAME:
Spirometry:
Beta Agonist/Anticholinergic Prescribed:
Is the patient on a statin? NoYes
Has your patient required/used more than a 15 day supply of
narcotic medica- tion over the last 12 months for a non-terminal
diagnosis? NoIf Yes, are there alternative options besides opioids
for the patient's pain? Yes No
Yes
//DOS: //DOB:Member Name:
Date:
Date:
NoYes
AbnormalNormal
*Osteoporosis Screening (67-85) y/o): Date:
Sigmoidoscopy (Every 5 yrs), Date: *Colorectal Cancer Screening
FOBT (Annual test b/t 50-75 yo), Date:Colonoscopy (Every 10 yrs),
Date:
*Influenza Vaccine (65+y/o): Date:
*Mammogram (52-74 y/o, every 27 mo.): Date
Pneumococcal Vaccine (65+y/o) Date Given:
Immunization(s) not carried out due to:
Prevnar (65+y/o) Date Given:
Living Will Advanced DirectiveDiscussion held Medical Power Of
Attorney*Advanced care planning: Date RESULT:
Stool DNA [Cologuard] (Every 3 yrs), Date: CT Colonography
(Every 5 yrs), Date:
Organ Donor
(guidelines recommend giving each pneumococcal vaccine one year
apart)
RENDERING NPI:
Shingles Vaccine: Date:
NoYes
Statin Prescribed:
874362 Rev. 01/2020
© 2020 Cigna
360 Comprehensive Assessment 2020
[ PLACE BARCODE HERE ]
Member First Name
DOB
(MM/DD/YYYY)
DOS
(MM/DD/YYYY)
Last Name
Member ID
PCP NPI
Rendering Provider
Member's PCP
Location
Source
Reason for Exam:
Past Medical History (this section intended only for
those conditions without an active treatment
plan):
*Please note: All HEDIS QRS metrics are asterisked for your
convenience
Surgical History:
*Medications: List all medications,
including OTCs, with dosage and frequency. Or, attach
printed, signed and dated list, and check here:
Allergies:
Difficulty taking or obtaining medication
Family History:
Father
Mother
Children
Siblings
Grandparents
HTN
Heart Disease
Stroke
Diabetes
Father
Mother
Children
Siblings
Grandparents
High Lipids
Dementia
Depression
Cancer
Habits:
Tobacco Use:
Alcohol Use:
Alcohol usage a concern
for you or others?
Social History:
Marital Status:
Lives:
High Risk for SexuallyAcquired Diseasesincluding
HIV:
Social/Difficulty handling finances:
Illicit Drug Use:
Current PhysicalActivity as comparedto last year:
Mobility:
How is your memory compared to last year?
Difficulty withbathing, toileting and dressing?
Difficulty withobtaining, preparing or eating food?
Vision:
Hearing:
Speech:
Require glasses
/contacts forroutine vision
Hearingissues /hearing aid
Private Residence
PCP Practice
Facility
Patient
Other (name & relationship)
Reviewed and No Past Medical History
CVA with no residual effect
History of Cancer (specify):
Reviewed and No Surgeries
No Current Medications
Medications Reviewed/Reconciled
No known drug allergies
Reviewed and No Relevant History
Yes
No
No
E-Cigarettes
Current Chew/Dip Use
Current Smoker, PPD
Previous Smoker, Year quit
Yes, Drinks per day
Yes
No
Yes
No
No
Yes
No
Yes
Single
Married
Divorced
Domestic Partner
Widowed
Alone
Spouse
Institutional
Family
Other:
More
Less
Same
Independent
Wheelchair
Bedbound
Walker
Transfer
difficulty
Cane
No
Yes
No
Same
Yes
Normal
Normal
Normal
Impaired
Form 360 Page 1 of 7
Worse
Better
Prior organ transplant (specify site/organ):
Annual 360 Comprehensive Assessment
Other
Unknown History
Difficulty driving ?
No
Yes
.\FootExam-JPG.JPG
*Fall Risk Screening: (mark all that apply)
Unable to perform exam b/c of
Diagnoses (3 or more existing)
Prior history of falls within 3 months
Incontinence
Visual Impairment
Impaired functional mobility
Environmental Hazard
Polypharmacy
Pain affecting level of function
Cognitive Impairment
TOTAL number of boxes marked
Fall Risk (4 or more reported)
Depression Screening (18 + y/o)
Have you felt depressed or down-and-out over the past 2
months?
Have you had a loss of interest in things that normally bring
you pleasure?
Have you felt fatigued or had a loss of energy recently?
If two or more "Yes" then complete PHQ-9 document, and attach
results to the 360 form:
*Urinary Incontinence Screening
During the last 3 months - have you leaked urine (even a small
amount)?
If Yes, please distribute education material
Screening not performed because the patient is unable to
communicate/answer.
Positive/Findings
Negative
Review of Systems
General
Cardiac
Respiratory
Gl
Musculoskeletal
Neurological
Skin
Psychiatric
Endocrine
Hematological
GU
HEENT
No
Yes
No
Yes
No
Yes
PHQ-9 form/Standard Screening Tool/Clinical Interview
PHQ-9 total score:
Pain treatment plan: if no pain = N/A
*Pain Screening
*Please assess the overall pain presence in the patient's
day-to-day life:
(all patients should have pain addressed, if no pain = 0,
has pain = 1 - 10)
0 1 2 3 4 5 6 7 8 9 10
Meds
Education
Pain doctor
PT
N/A
Other
Right
Left
5. Complications due to diabetes: (check all that apply)
4. Test for neuropathy:
Posterior Tibial
Dorsalis pedis
3. Check for foot pulse:
2. Look at both feet:
1. Ask the patient:
Foot Exam: (Complete for diabetic
patients and/or patients with neuropathic complaints)
Weak
Absent
Normal
Weak
Absent
Normal
Abnormal
Normal
RIGHT
LEFT
Key:
+ = Sensation
= No Sensation
Absent
Absent
Weak
Weak
Normal
Normal
Left Monofilament
Right Monofilament
Abnormal
Normal
None of these
Ulcer
Peripheral neuropathy
Peripheral vascular disease
Gangrene
Amputation: date, side & level:
Infection
Ulceration
Skin breaks
Calluses or corns
Foot deformity
Nail disorders
None of these
Burning, tingling, numbness in feet
Pain or cramping in calf area during exercise
Previous foot ulcer
Yes
No
None of
these
Form 360 Page 2 of 7
/
/
DOS:
/
/
DOB:
Member Name:
THIS SECTION SHOULD NOT INCLUDE AN ACTIVE DIAGNOSIS.
Form 360 Page 3 of 7
Vitals:
*Ht (in):
*Wt (lbs):
*BMI:
Temp (F0):
*BP:
/
HR:
RR:
Gender:
Male
Female
Deferred
Deferred
Deferred
General
Comprehensive
Exam
Normal
Neck
Heart
Lungs
Breast
Abdomen
Extremities
GU
Musculoskeletal
Neurological
Skin
HEENT
Psychiatric
Hematologic
Lymphatic
Abnormal/Findings (check box [norm] or abnormal exam for each
[except deferred] required)
Treatment Plan:
Cardiovascular:
Current Conditions:
Reviewed and No Active Disease
Meds
Monitor
Diet
Labs
Referral
.
.
Referral
Labs
Diet
Monitor
Meds
Reviewed and No Active Disease
Nutritional/Metabolic/Endocrine:
w/o Pacemaker
Persistent
Left
Systolic & Diastolic
Permanent
Right
Systolic
Primary
Secondary
Mixed
Other (specify):
w/ Pacemaker
Chronic
Side:
Diastolic
CAD w/Angina Pectoris
Tachycardia
Sick Sinus Syndrome:
Atrial Fibrillation
Carotid artery stenosis
Hyperlipidemia If no statin, name of med
CHF:
Cardiomyopathy Type (specify):
CAD
Angina Pectoris
Myocardial infarction
w/o CHF
w/CHF(note: add specific CHF above)
HTN heart disease w/o CHF
Other Diagnosis (specify):
Peripheral Artery Disease
Hypertensive Heart and CKD (note: add specific stage of CKD
to renal section)
Hypertensive CKD (note: add specific stage of CKD to renal
section)
HTN heart disease w/CHF (note: add specific CHF
above)
*Hypertension: Date of Diagnosis:
Presence of Internal Cardiac Defib
Other Diagnosis (specify):
Hyperthyroidism
Hypothyroidism
Pre-diabetes
Obesity (BMI 30 - 39.9)
Acquired (post surgical)
For BMI 35.0 - 39.9, document co-morbidity (i.e. HTN
&/or DM)
Moderate
Mild
Protein Calorie Malnutrition
Vascular Disease
/
/
DOS:
/
/
DOB:
Member Name:
Type (specify):
Valvular disease
Overweight (BMI 25.0 - 29.9)
Left sided
Right sided
Morbid Obesity (BMI > 40)
Date:
Pulmonary Hypertension
Vessel(s):
native
graft
Aortic
Pulmonic
Tricuspid
Stenosis
Regurgitation
Mitral
Non-Rheu
Rheu
Abd Aortic Aneurysm
Thoracic Aortic Aneurysm
Cachexia
..\..\Print\ARR_R.TIF
Form 360 Page 4 of 7
Diabetes Mellitus: document all co-morbid
manifestations
Reviewed and No Active Disease
DM:
Type 1
Type 2
DM w/ Secondary Kidney Complications:
CKD (note: include stage in renal section)
Nephropathy
DM w/ Secondary Neurological Complications:
Mononeuropathy
Polyneuropathy
Other:
Gastroparesis
Meds
Monitor
Diet
Labs
Referral
Referral
Labs
Diet
Monitor
Meds
Referral
Labs
Diet
Monitor
Meds
Referral
Labs
Diet
Monitor
Meds
Side:
Right
Left
Severe
w/ Macular Edema
Cataract
Mild
Proliferative
Retinopathy:
DM w/ SecondaryOphthalmic Complications:
Moderate
Non-proliferative
Glaucoma
Location (specify):
Non-Pressure Chronic Ulcer
DM w/ Secondary Skin Complications:
w/o Gangrene
Peripheral Angiopathy/PVD
DM w/ Secondary Circulatory Complications:
w/ Gangrene
Right
Left
Side:
DM w/ Oral Complications:
Periodontal
Other:
DM w/arthropathy:
Neuropathic
Other:
Hyperglycemia
Hypoglycemia
DM w/ Other Secondary Complications:
Mixed
Mucopurulent
Simple
Obstructive
w/ Oxygen Dependence
Centrilobular
Panlobular
Mesothelioma
Location:
Unilateral
Other:
Emphysema:
COPD:
Chronic Bronchitis:
Respiratory:
Other Diagnosis (specify):
Tracheostomy
Pulmonary Fibrosis
Sarcoidosis
Obstructive Sleep Apnea
w/ Exacerbation
Bronchiectasis:
Asthma:
Chronic Obstructive
Severe
Moderate
Mild
Persistent
Intermittent
w/ Acute Lower Respiratory Infection
Asbestosis
Chronic Respiratory Failure
Osteoporosis Location(s):
Osteopenia Location(s):
Osteoarthritis Location(s):
Psoriatic Arthritis
Systemic Lupus Erythematous
*Rheumatoid Arthritis; Last DMARD Rx fill date
Reviewed and No Active Disease
Musculoskeletal:
Other Diagnosis (specify):
Location:
S/P Amputation
Side:
Right
Right
Right
Left
Left
Left
Side:
Side:
Left
Right
Left
Right
Type:
Senile
Postmenopausal
Unspecified
Yes
No
Has the patient had a fracture in the past 12 months?
If a fracture occurred, note specific bone location:
*Last Bone Density:
Yes
No
Other Diagnosis (specify):
Both
Left
Right
Location (specify):
Non Pressure Ulcer:
Unstageable
Stg 4
Stg 3
Stg 2
Stg1
Pressure Ulcer:
Skin/Subcutaneous:
w/Exacerbation
Reviewed and No Active Disease
Insulin
Oral meds
Reviewed and No Active Disease
/
/
DOS:
/
/
DOB:
Member Name:
If no DMARD document rationale
Diabetes w/osteomyelitis
Name of rheu arthritis med
Bisphosphonate medication
Start Date of Osteoporosis medication:
Denosumab
Yes
No
Form 360 Page 5 of 7
Renal/Urinary:
Chronic Kidney Disease (CKD)
CKD unspecified
Meds
Monitor
Diet
Labs
Referral
Erectile dysfunction
Secondary hyperparathyroidism of renal origin
Referral
Labs
Diet
Monitor
Meds
*Urine Microalbumin Result:
Date:
eGFR:
Referral
Labs
Diet
Monitor
Meds
AV Fistula:
Graft
Catheter
No
Yes
Dialysis:
ESRD
Stage 5 (GFR90)
(Provided GFRs need to be consistent for more
than a 3 month period)
Referral
Labs
Diet
Monitor
Meds
Reviewed and No Active Disease
Gastrointestinal:
Reviewed and No Active Disease
Non-Alcoholic
Alcoholic
Ileostomy
w/o Diarrhea
w/ Diarrhea
G Tube
Other Diagnosis (specify):
Chronic Hepatitis - specify type:
J Tube
IBS
Ulcerative Colitis, if complications exist
specify
Crohn's Disease location(s):
GERD
Colostomy
End stage liver disease
Cirrhosis liver:
Pancreatitis (chronic):
Other Diagnosis (specify):
Cystostomy
Urge
Stress
Unspecified
w/o LUTS
w/ LUTS (specify):
BPH
Urinary Incontinence (check one):
Left
Left
Right
Right
Side:
Side:
Nonexudative
Other Diagnosis (specify):
Exudative
Legal Blindness
Macular Degeneration
Glaucoma
Cataract
Senile
Reviewed and No Active Disease
Eye:
Metastatic and if so, to what site(s)?
Left
Right
If Ductal Carcinoma in situ
Hormonal therapy
Date:
Date:
Radiation
Left
Chemo
Right
Mastectomy:
Neoplasm breast site
Treatment:
Breast Cancer
Metastatic and if so, to what site(s)?
Radiation
Chemo
Colectomy Date:
Colon Cancer
Reviewed and No Active Disease
Active Neoplasm/Blood Disorders and Current Treatment:
Other Malignancies (specify):
Melanoma in Situ (site):
Skin Cancer (type and site):
Metastatic and if so, to what site(s)?
Radiation
Other:
Chemo
Lower Lobe
Pneumonectomy
Upper Lobe
L
Lobectomy
R
Treatment:
Lung Cancer
Metastatic and if so, to what site(s)?
Treatment:
Prostatectomy
Prostate Cancer
Active Neoplasm/Blood Disorders and Current
Treatment: Continued on Next Page
DOS:
DOB:
Member Name:
/
/
/
/
Unilateral
Bilateral
Left
Right
Left
Right
Form 360 Page 6 of 7
Referral
Labs
Diet
Monitor
Meds
Referral
Labs
Diet
Monitor
Meds
Relapse
In Remission
Current
Drug-induced Neutropenia (specify drug):
Multiple Myeloma
Myelodysplastic Disease
Other Diagnosis (specify):
AIDS
HIV+
General
Iron
Other:
B-12
Drug - induced (specify drug):
Sickle Cell
Due to Chemotherapy
Due to CKD
Anemia:
Lower Limb
Right
Left
Right
Left
Right
Left
Right
Left
Lower Limb
Right
Left
Upper Limb
Non-dominant
Non-dominant
Non-dominant
Non-dominant
Upper Limb
Non-dominant
Dominant
Dominant
Dominant
Dominant
Dominant
Other:
Speech/Language
Dysphagia
Cognitive (specify):
Monoplegia
Hemiplegia/Hemiparesis
History of Trauma
Weakness
Hemiplegia/Hemiparesis
Monoplegia
Specify late effect:
CVA w/ Sequlae: (note: specify below)
Reviewed and No Active Disease
Neurological:
Psychiatric:
Reviewed and No Active Disease
Mild
Major
If Major:
Mild
Moderate
Severe
Partial Remission
Full Remission
Recurrent
Single Episode
w/ Psychotic Symptoms (consider psych referral if s/sx presents,
recurrent, or suicidal)
w/o Psychotic Symptoms
w/o Psychotic features
w/ Psychotic features
Partial )
Full
In Remission (
Current
Bipolar
Anxiety
If Severe:
If Major:
Depressive Disorder
w/ Behavioral Disturbances
w/ Dementia
Seizure Disorder (Epilepsy)
Other Diagnosis (specify):
Seizures
Parkinson's Disease:
Polyneuropathy other than due to diabetes, specify
ALS
Myasthenia gravis
Multiple Sclerosis
Quadriplegia
Other Diagnosis (specify):
In Remission Specify:
Dependence
Sbst. Abuse
Substance Use
In Remission
Alcohol Dependence
Alcohol Abuse
Alcohol Use
Other (specify):
Disorganized
Undifferentiated
Simple
Paranoid
Schizophrenia
Severe
Moderate
Mild
Current severity:
Mixed
Manic
Depressed
Current type:
Dementia:
Alzheimer's disease:
Unspecified
Vascular
w/ Delusions
w/ Depression
Senile
Early Onset
Late Onset
w/ Dementia
w/ Dementia and Behavioral Disturbance
Aphasia
Referral
Labs
Diet
Monitor
Meds
Active Neoplasm/Blood Disorders and Current Treatment
(Continued)
/
/
DOS:
/
/
DOB:
Member Name:
..\..\Print\ARR_R.TIF
Tobacco dependence
Form 360 Page 7 of 7
Anticonvulsants (Phenobarbital, Carbamazepine, Phenytoin,
Valproic acid):
Preventive Medicine: (Please Use "D" if patient declines, N/A,
"S" for scheduled, or "A" for advised)
Date
Result:
Result:
Result:
Long Term Medication Monitoring (Annual)
Reviewed
*Patients diagnosed with Diabetes:
*HbA1C:
*Microalbuminuria: Date
*Retinal Eye Exam: Date
*Name of Eye Care Provider:
Opioid Evaluation:
Patients diagnosed with COPD:
Patients diagnosed with CHF and/or CAD:
Serum Drug Concentration:
No
Yes
No
Yes
Result:
ACE or ARB Prescribed:
Beta Blocker Prescribed:
LVEF Assessment Date:
Describe
Other
Referral
Labs
Diet
Monitor
Meds
SELECT TREATMENT PLAN
DIAGNOSES
Please list any diagnoses, not already noted under current
conditions, which affect patient care, treatment or management.
COORDINATION OF CARE (Please list any providers/specialists
involved in the patient's care and any supplier of equipment):
PLAN:
None
HMR reviewed and updated on today's visit?
BEHAVIORAL HEALTH REFERRAL:
CASE MANAGEMENT REFERRAL:
No
Yes
No
Yes
No
Yes
Care Coordination
If Yes, please specify:
Social Concerns
Patient Education
Other (specify):
Indication:
I discussed the following with my patient:
OTHER COMMENTS:
Patient Email (OPTIONAL)
Tobacco cessation and education
*Urinary incontinence
*Physical Activity
*Fall risk prevention
Other (specify):
Diet Modification
90 Day Rx Fill
High Risk Medications
PA
NP
DO
MD
DO
MD
SUPERVISING PHYSICIAN NAME:
(if applicable)
DATE:
SUPERVISINGPHYSICIAN SIGNATURE:
(if applicable)
DATE:
RENDERING SIGNATURE:
RENDERING NAME:
Spirometry:
Beta Agonist/Anticholinergic Prescribed:
Is the patient on a statin?
No
Yes
Has your patient required/used more than a 15 day supply of
narcotic medica- tion over the last 12 months for a non-terminal
diagnosis?
No
If Yes, are there alternative options besides opioids for
the
patient's pain?
Yes
No
Yes
/
/
DOS:
/
/
DOB:
Member Name:
Date:
Date:
No
Yes
Abnormal
Normal
*Osteoporosis Screening (67-85) y/o): Date:
Sigmoidoscopy (Every 5 yrs), Date:
*Colorectal Cancer Screening FOBT (Annual test b/t 50-75
yo), Date:
Colonoscopy (Every 10 yrs), Date:
*Influenza Vaccine (65+y/o): Date:
*Mammogram (52-74 y/o, every 27 mo.): Date
Pneumococcal Vaccine (65+y/o)
Date Given:
Immunization(s) not carried out due to:
Prevnar (65+y/o) Date Given:
Living Will
Advanced Directive
Discussion held
Medical Power Of Attorney
*Advanced care planning: Date
RESULT:
Stool DNA [Cologuard] (Every 3 yrs), Date:
CT Colonography (Every 5 yrs), Date:
Organ Donor
(guidelines recommend giving each
pneumococcal vaccine one year
apart)
RENDERING NPI:
Shingles Vaccine: Date:
No
Yes
Statin Prescribed:
11.0.0.20130303.1.892433.887364
Dr Michael Fessenden - Jason Jean
01/2020
874362 PRINT PDF(MASTER PRINT VERSION)
Co-Owners: Dr. Michael Fessenden & Michele (Donna)
Prichard
IT OPS - ODS/AFDDS, Maxx McKinlay
Cigna HealthSpring Comprehensive Assessment 2020
Cigna HealthSpring
MemberFirstName: NPI: MemberLastName: MemberID:
RenderingProvider: MembersPCP: DOS: / /DOB: / /PrivateResidence:
PCP_Practice: Facility: Patient: Other: ResolvedCondition8:
ResolvedCondition7: ResolvedCondition6: ResolvedCondition5:
ResolvedCondition4: ResolvedCondition3: ResolvedCondition2:
ResolvedCondition1: HistoryOfCancer: 0CVA_NoResidualEffect:
0NoPastMedicalHistory: 0NoSurgeries: 0SurgicalHistory2:
SurgicalHistory3: SurgicalHistory4: SurgicalHistory5:
SurgicalHistory6: SurgicalHistory7: SurgicalHistory8:
SurgicalHistory9: MedicationAndOTCDisclaimer: 0NoCurrentMedication:
0MedicationsReviewed: 0ObtainMeds: 0MedicationAndOTC2:
MedicationAndOTC3: MedicationAndOTC4: MedicationAndOTC5:
MedicationAndOTC6: MedicationAndOTC7: NoDrugAllergies: 0Allergies1:
Allergies2: Allergies3: Allergies4: Allergies5: NoFamilyHistory:
0FamilyHistoryOther: Father_HTN: 0Father_HeartDisease:
0Father_Stroke: 0Father_Diabetes: 0Mother_HTN:
0Mother_HeartDisease: 0Mother_Stroke: 0Mother_Diabetes:
0Children_HTN: 0Children_HeartDisease: 0Children_Stroke:
0Children_Diabetes: 0Siblings_HTN: 0Siblings_HeartDisease:
0Siblings_Stroke: 0Siblings_Diabetes: 0Grandparents_HTN:
0Grandparents_HeartDisease: 0Grandparents_Stroke:
0Grandparents_Diabetes: 0Father_HighLipids: 0Father_Dementia:
0Father_Depression: 0Father_Cancer: 0Father_Other:
0Mother_HighLipids: 0Mother_Dementia: 0Mother_Depression:
0Mother_Cancer: 0Mother_Other: 0Children_HighLipids:
0Children_Dementia: 0Children_Depression: 0Children_Cancer:
0Children_Other: 0Siblings_HighLipids: 0Siblings_Dementia:
0Siblings_Depression: 0Siblings_Cancer: 0Siblings_Other:
0Grandparents_HighLipids: 0Grandparents_Dementia:
0Grandparents_Depression: 0Grandparents_Cancer:
0Grandparents_Other: 0Yes: No: Tobacco_ECigs: 0Tobacco_ChewDip:
0Tobacco_CurrentSmoker: 0Tobacco_PreviousSmoker: 0Single: Married:
Divorced: Widowed: Alone: Spouse: Institutional: Family: More:
Less: Same: Independent: Transfer: Cane: Walker: Wheelchair:
Bedbound: Normal: 0NeedsGlassesOrContacts:
HearingIssues_HearingAid: Impared: AnnualCompExam: 0UnknownHist:
0FallRisk_Diagnoses_3OrMore: 0FallRisk_Incontinence:
0FallRisk_PriorHistory: 0FallRisk_VisualImpairment:
0FallRisk_ImpairedFunctionalMobility:
0FallRisk_EnvironmentalHazard: 0FallRisk_Polypharmacy:
0FallRisk_PainAffectingFunctionLevel:
0FallRisk_CognitiveImpairment: 0FallRisk_4OrMoreReported:
0Depression_PatientUnableToAnswer: 0Depression_PHQ-9Form:
0ROS_General_Neg: 0ROS_HEENT_Neg: 0ROS_Cardiac_Neg:
0ROS_Respiratory_Neg: 0ROS_GI_Neg: 0ROS_Musculoskeletal_Neg:
0ROS_Neurological_Neg: 0ROS_Skin_Neg: 0ROS_Psychiatric_Neg:
0ROS_Endocrine_Neg: 0ROS_Hematological_Neg: 0ROS_GU_Neg: 0Plan_NA:
0Plan_Other: 0Plan_PainDoctor: 0Plan_PT: 0Plan_Education:
0Plan_Meds: 0PS0: PS1: PS2: PS3: PS4: PS5: PS6: PS7: PS8: PS9:
PS10: NoneOfThese: 0FootDeformity: 0NailDisorders: 0SkinBreaks:
0CallusesOrCorns: 0Ulceration: 0Infection:
0BurningTinglingNumbness: 0PainOrCrampingInCalfDuringExcerise:
0PreviousFootUlcer: 0Weak: 0Absent: 0Abnormal: 0Gangrene:
0PeripheralNeuropathy: 0PeripheralVascularDisease: 0Ulcer: 0Neck:
0Heart: 0Lungs: 0Breast: 0Abdomen: 0Extremities: 0GU2: 0Musk2:
0Neruo: 0Skin: 0Lumph: 0Hemat: 0Physic: 0RR: HR: Temp1: BMI-1:
Weight: HeightInches: BPHigh: BPLow: BMI-2: Temp2:
PE_HematologicDeferment: 0PE_GUDeferment: 0PE_BreastDeferment:
0CC_HistoryOfMI_SpecifyDate: 0CC_AnginaPectoris: 0CC_CAD:
0CC_Cardiomyopathy: 0CC_CongestiveHeartFailure: 0CC_Hyperlipidemia:
0CC_CarotidArteryStenosis: 0CC_AtrialFibrillation:
0CC_SickSinusSyndrome: 0CC_TachycardiaType:
0CC_SickSinusSyndrome_WO-Pacemaker:
0CC_AtrialFibrillation_Persistent: 0CC_CarotidArteryStenosis_Left:
0CC_CongestiveHeartFailure_CombinedSystolicDiastolic:
0CC_AtrialFibrillation_Paroxysmal: 0CC_CarotidArteryStenosis_Right:
0CC_CongestiveheartFailure_Systolic:
0CC_SickSinusSyndrome_W-Pacemaker: 0CC_AtrialFibrillation_Chronic:
0CC_CongestiveHeartFailure_Diastolic: 0CC_CAD_CADW-AnginaPectoris:
0CC_HistoryOfMI: 0Hypoth: 0Hyperten: 0OtherDiag: 0PeripheralArt:
0HyperHeartC: 0HypertCD: 0HypertenHD: 0HyperHeartWF: 0HypertenHdF:
0HyperHeartWoF: 0Protein: 0PosPro: 0ModPro: 0ObeseClass2:
0HypoAdqu: 0MorObes: 0Hyperth: 0SpecOtherDiag: 0ReviewNut:
0Hyperten1: 0Hyperten2: 0Hyperten3: 0Hyperten4: 0Hyperten5:
0HypertenHD1: 0HypertenHD2: 0HypertenHD3: 0HypertenHD4:
0HypertenHD5: 0HypertCD1: 0HypertCD2: 0HypertCD3: 0HypertCD5:
0HyperHeartC1: 0HyperHeartC2: 0HyperHeartC3: 0HyperHeartC4:
0HyperHeartC5: 0PeripheralArt1: 0PeripheralArt2: 0PeripheralArt3:
0PeripheralArt4: 0PeripheralArt5: 0OtherDiag1: 0OtherDiag2:
0OtherDiag3: 0OtherDiag4: 0OtherDiag5: 0Protein1: 0Protein2:
0Protein3: 0Protein4: 0Protein5: 0Obese1: 0Obese2: 0Obese3:
0Obese4: 0Obese5: 0Hypoth1: 0Hypoth5: 0Hypoth4: 0Hypoth3: 0Hypoth2:
0SpecOtherDiag1: 0SpecOtherDiag2: 0SpecOtherDiag3: 0SpecOtherDiag4:
0SpecOtherDiag5: 0CardioReview: 0CC_Valvular: 0Overweight:
0CHF_Left: 0CHF_Right: 0CC_HistPulmHy_PulmHypert: 0Hyperth1:
0Hyperth2: 0Hyperth3: 0Hyperth4: 0Hyperth5: 0ReviewDiabetes:
0DMType1: 0DMwSec: 0Gastro: 0CCDiabetMelit1: 0DMSecKid1: 0DMwSN1:
0Ophthalmic1: 0CCDiabetMelit2: 0DMSecKid2: 0DMwSN2: 0Ophthalmic2:
0CCDiabetMelit3: 0DMSecKid3: 0DMwSN3: 0Ophthalmic3:
0CCDiabetMelit4: 0DMSecKid4: 0DMwSN4: 0Ophthalmic4:
0CCDiabetMelit5: 0DMSecKid5: 0DMwSN5: 0Ophthalmic5: 0DMType2:
0ChronicType: 0KidNeph: 0DMwSNMono: 0DMwPeri: 0DMwSNother:
0DMwSecRetin: 0DMwSecProl: 0DMwSecMild: 0DMwSeCat: 0DMwGlac:
0DMwSecMod: 0DMwSecNProl: 0DMwSev: 0DMwSecMac: 0DMwSec_Right:
0DMwSec_Left: 0DMwSecComp: 0DMwSecCompPeri: 0DMwSecCompwo:
0DMwSecCompG: 0DMwSecComp1: 0DMwSecComp2: 0DMwSecComp3:
0DMwSecComp4: 0DMwSecComp5: 0PrintOnly: 0PrintOnly1: 0PrintOnly2:
0PrintOnly3: 0PrintOnly4: 0PrintOnly5: 0DMwSN: 0DMSecKid:
0CDiabetMelit: 0DMTypeDep: 0CCDiabetwOsteom5: 0CCDiabetwOsteom4:
0CCDiabetwOsteom3: 0CCDiabetwOsteom2: 0CCDiabetwOsteom1:
0CCDiabetwOsteom: 0Print: 0Tabbco5: 0Tabbco4: 0Tabbco3: 0Tabbco2:
0Tabbco1: 0TobaccoDep: 0PatientEmail:
