AHA 2012 Draft

of 6 Annual Health Assessment 2012 MM/ DD/YYYY MM/DD/YYYY Health Plan Name: Date of Visit: Member Name: Member ID: Provider Name: Billing NPI: Date of Birth: Gender: F M Rendering NPI: History of Present Illness: Recent Hospitalization? Yes No Date: Recent Surgery? Yes No Date: Transportation: Self Depends on: Allergies: Yes No Discussion regarding Advance Directives? Yes No Date: Family History Condition Mother Father Siblings DM CVD Cholesterol Cancer Alzheimer Other: General Counsel / Habits Counsel if at risk for STDs: Yes No N/A At risk for HIV: Yes No N/A Counsel on tobacco use: Yes No N/A Counsel on illicit drug use: Yes No N/A Counsel on alcohol misuse: Yes No N/A Medication Review: Patient / Caregiver Questions Yes No 1. Patient has knowledge his/her medications by name/use. 2. Patient can identify the frequency of his/her medications. 3. Patient administrates medications as prescribed. Cross Reference Number: (Do not write on this area for official use only) PRESENT, PAST AND SOCIAL HISTORY: Advance Directives on file at: Office / Hospital Comments: Family Environment (e.g. Live with spouse, caregiver etc.): Past Medical History:

AHA 2012 Draft

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