Welcome to Medicare Preventive Visit Documentation
Document essential patient and provider information for the initial Medicare preventive visit, including health history, screenings, and preventive services.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Contact Information
*
Provider Full Name
*
First Name
Last Name
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical History (e.g., chronic conditions, past surgeries)
*
Current Medications (list all prescribed and over-the-counter medications)
*
Family History of Major Illnesses
Health Risk Assessment
*
Rows
Yes
No
Tobacco use
1
2
Alcohol use
3
4
Physical inactivity
5
6
Poor nutrition
7
8
Depression screening
9
10
Screenings and Preventive Services Provided
*
Blood pressure measurement
Height, weight, and BMI
Vision screening
Hearing screening
Immunization review
Other (please specify)
Additional Notes or Recommendations
Patient Signature
*
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