Blank Medicare Health Risk Assessment Form

6/25/14 V.3
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MEDICARE(HEALTH(RISK(ASSESSMENT(
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Date of Exam:
MMDDYYYY!
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(((((((((Examiner(NPI:(
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! ! ! ! ! ! ! ! ! ! ! ! ! MD! DO!
Last!Name,!First!Name!
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HH:MM
AM
PM
Exam End Time:
HH:MM
AM
PM
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Member Information
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Name:
Race/Ethnicity: ________________ Sex: ____
Language: __________________
DOB: / /
Address:
Home Phone:
Cell Phone:
HPM Member ID#:
Member’s PCP:
PCP’s Address:
Advanced Care Planning
Advanced
directive
Yes
No
Has health care proxy? Yes
No
Has living will? Yes
No
Allergies & Reported Reactions
No known drug
allergies
Known
drug
allergies
List of Allergies: ____________________
___________________________________
___________________________________
Reported reactions: ________________
__________________________________
__________________________________
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Family History
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Who lives in same household with applicant? (if none write “none” in space.)
Name
Age
Relationship
Remarks
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Page 1/11
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Blank Medicare Health Risk Assessment Form PDF

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