WELCOME TO MEDICARE VISIT: INITIAL PREVENTIVE PHYSICAL EXAMINATION

Patient: [Name, date of birth]
Visit date: [Date]
Code: [G0402; add G0403, G0404, or G0405 if a screening ECG is done]

ELIGIBILITY
Part B start date: [Date; today is within the first 12 months: yes or no]
Earlier IPPE: [None on the eligibility check, or the date found]
Clinician: [Name; physician, physician assistant, nurse practitioner, or clinical nurse specialist]
In the room: [Spouse, adult child, caregiver, interpreter, or nobody else]

MEDICAL AND SOCIAL HISTORY
Illnesses and treatments: [Past and current conditions, with the treatments tried]
Operations, hospital stays, and injuries: [Each one, with the year]
Allergies: [Drug, food, or other, and the reaction; or no known allergies]
Medicines and supplements: [Every prescription and over-the-counter product, calcium, vitamins, and any other substance used, with dose and who prescribed it]
Family history: [Conditions in relatives that may be inherited or raise this patient's risk, with ages]
Tobacco: [Never, former, or current; pack-years; year quit]
Alcohol: [Usual drinks per week and the most on one day]
Other drugs: [Cannabis, illicit drugs, or misuse of prescriptions, or none]
Diet: [Typical day of eating and drinking]
Physical activity: [What, and minutes per week]
Social engagement: [Work, volunteering, groups, family contact, or isolation]

DEPRESSION RISK
History: [Past or current depression or other mood disorder, or none]
Screen: [Standardized tool and score, such as PHQ-2, with PHQ-9 if positive; not needed with a current depression diagnosis]
Self-harm: [Asked directly if the screen is positive: answer]

FUNCTION AND SAFETY
Activities of daily living: [Bathing, dressing, eating, toileting, moving about: independent, or the help needed]
Fall risk: [Falls in the past year, unsteadiness, fear of falling]
Hearing: [Concerns, quick screen result, hearing aids]
Home and community safety: [Stairs, smoke alarms, firearm storage, and driving when it applies]

EXAM
Height: [cm or in]
Weight, BMI, and waist: [Weight; BMI; waist circumference if it fits better]
Blood pressure: [Reading; repeat after rest if high]
Visual acuity: [Chart used; each eye; with or without glasses]
Balance and gait: [Observed walk, chair stand, or timed test, and the result]
Other: [Any further check the history calls for, or none]

END-OF-LIFE PLANNING
Agreed to discuss: [Yes, or declined]
Advance directive: [Has one, will prepare one, or not wanted; health care agent named]
Your answer: [Whether you will follow the patient's directive, as told to them]

OPIOID REVIEW AND SUBSTANCE USE SCREEN
Current opioid prescriptions: [None, or each drug, dose, prescriber, and how long]
Risk factors for opioid use disorder: [Found, or none]
Pain and current plan: [Severity, effect on function, treatments in use]
Non-opioid options: [What you discussed]
Specialist referral: [Where, or not needed]
Substance use risk factors: [Alcohol, drugs, family history, mental health, or none]
Substance use tool: [Name and score, such as AUDIT-C, or questions only]
Referral for treatment: [Where, or not needed]

EDUCATION, COUNSELING, AND REFERRALS
From today's findings: [Each finding, numbered, with the advice given or referral made]

WRITTEN SCREENING AND PREVENTION PLAN
Screening ECG: [Done today with the result, referred elsewhere, or not indicated and why]
Screening tests: [Each test due, with the date of the last one and when the next is due]
Vaccines: [Given today, due, or complete]
Checklist given: [On paper, through the portal, or by mail]

Separate problem care today: [None, or the problem, documented apart and billed with modifier 25]
Next preventive visit: [First AWV, no sooner than 12 months from today]

Signed: [Name, credentials, date and time]