Annual Wellness Visit Questions - Demo

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Annual Wellness Visit Questions

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Introduction (Show the following message at the beginning): Hello, my name is Emma and I am going to help you complete the questionnaire portion of your Annual Wellness Visit. The information that you provide will be summarized for your physician and is needed to complete the exam. This process will take about 15 minutes to complete. If you must stop, you can come back at a later time to finish. If you want me to repeat a question, just say “repeat”. Are you ready? (Section 1). Patient Please spell your full name and date of birth. [can we display the name and ask the patient if it is correct and if not ask the patient to spell it out? Can we have the patient confirm the date of birth? ] Please specify your gender. such as Male, Female. (Section 2). List of Current Providers Please say and spell the name of your primary care physician. Do you have any other physicians that you see regularly? If no, move on, If yes say Please say and spell the name of other physicians that you see and include the specialty. For example, Dr. Smith, S M I T H, cardiology. Do you see any other physicians? (repeat after each physician if there is a >2 second pause. Move on if the answer is no.) (Section 3). Patient’s Medical and Family History What medical conditions are you treated for? (repeat if there is >2 second pause. Move on if the answer is none.) Have you had any surgery in the past? If yes, ask what type of surgery? If there is a >2 second pause ask “any other surgeries and repeat if there is a >2 second pause. Move on if the answer is no.) Have you been hospitalized in the past? If no move on. If yes, When were you hospitalized and for what conditions? Any other hospitalizations? If no move on. If yes, when and for what condition, Do you take prescription medications? If no, move on, If yes, ask Which prescription medication do you take? It’s ok to spell them out. Be sure to tell me the dosage and how many times a day you take it? Any other medication? (Repeat after each medication if there is a >2 second pause. Move on if the answer is no.) [we should have the patient confirm the medication by viewing on the screen ] Are you allergic to any medication? (If yes ask “which one”) Any other allergies? (Repeat if there is a > 2 second pause. Move on if the answer is no.) Please tell me about your family’s medical history. What diseases have occurred in your family and in which family member. Any others?”. (Repeat if there is a >2 second pause, Move on if the answer is no.) (Section 4). Cognitive Ability I am now going to ask you some questions to test your mental ability. What day of the week is it? What is the year? What state are we in? Please remember these five objects. I will ask you what they are later. - Apple Pen Tie House Car You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20. - How much did you spend? (correct answer get 1) - How much do you have left? (correct answer get 1) Please name as many animals as you can in one minute. (Instructions for scoring: 0-4 animals get 0, 5-9 animals get 1, 10-14 animals get 2, 15+ animals get 3) What were the five objects I asked you to remember? I am going to give you a series of numbers and I would like you to give them to me backwards. For example, if I say 42, you would say 24. - 87 (correct answer get 0) - 648 (correct answer get 1) - 8537 (correct answer get 1) This is a clock face. Please put in the hour markers and the time at ten minutes to eleven o’clock. ) - (draw_zone: [clock_panel_picture ]{ 0, 0, 320, 320 }) (correct answer get 1) (Instructions for scoring: Hour markers okay get 2, Time correct get extra 2) Please place an X in the triangle. ) - (draw_zone: [triangle-picture ]{ 0, 0, 179, 87 }) (correct answer get 1) Which of the the figures is largest. ) (correct answer get 1) I am going to tell you a story. Please listen carefully because afterwards, I'm going to ask you some questions about it. *Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a devastatingly handsome man. She married him and had three children. They lived in Chicago. She then stopped work and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after.* - What was the female’s name? (preference: name could be Jill) (correct answer get 2) - When did she go back to work? (correct answer get 2) - What work did she do? (correct answer get 2) - What state did she live in? (correct answer get 2) (Instructions for scoring Cognitive Ability, it is the total score of above questions. For HIGH SCHOOL EDUCATION user, 27-30 means NORMAL, 21-26 means MILD NEUROCOGNITIVE DISORDER, 1-20 means DEMENTIA; For LESS THAN HIGH SCHOOL EDUCATION user, 25-30 means NORMAL, 20-24 means MILD NEUROCOGNITIVE DISORDER, 1-19 means DEMENTIA) (Section 5) Health Risk Assessment Do you drink alcoholic beverages? If yes, ask the following 2 questions. Move on if the answer is no. If Yes, how many drinks do you have each week on average. If yes, what type of alcoholic beverage do you drink? Do you currently smoke cigarettes? If yes ask “How many cigarettes do you smoke each day? For how many years have you smoked?, Are you ready to quit?” Move on if the answer is no. Did you smoke cigarettes in the past? If yes ask “How many cigarettes did you smoke each day? How many years did you smoke? When did you quit?” Move on if the answer is no. Do you use any other tobacco products or illegal drugs? If yes ask “which ones?” If no, move on. (Section 6). Biometrics What was your blood pressure the last time it was checked? Have you ever been told that you have high cholesterol? Have you ever been told by a doctor that you have diabetes ? What is your height? What is your weight? (Section 7). Depression Assessment Over the last 2 weeks, how often have you had symptoms like little interest or pleasure in doing things, feeling depressed or hopeless? Not at all, Several days, more than half the days, nearly every day (Section 8). Functional Ability and Safety The next questions are about how well you can take care of yourself. Do you need help doing your daily chores? Have you fallen in the past year? (Section 9). Pain and Pain Medication Do you have pain that interferes with performing desired activities? Do you take pain medication? (If yes, ask “what pain medication do you take?” If no, move on.) End. (Show the following information when questionary complete) Thank you for your time! Your information has been saved. We’ll share this with your healthcare provider. You’re all set! We’ll contact you soon with your appointment details. If you have any questions, call us directly. we will see you at your appointment. )