Welcome to Medicare Form 12 MEDICARE INITIAL PREVENTIVE PHYSICAL EXAMINATION ENCOUNTER FORMPatient Name(Required) First Last Date of Birth(Required) Month Day Year Date of Exam(Required) Month Day Year Phone(Required)Email MEDICAL/SOCIAL HISTORYList past personal illnesses or injuriesto add more to the list, select the + button to the right of the fieldInjury or IllnessDateHospitalized (yes or no) Add RemoveFamily History Notes(Required)if none, type "NONE"Medications/Supplements/Vitamins(Required)if none, type "NONE"Drug Allergies(Required)if none, type "NONE"Do you drink alcohol?(Required)NoYesHow much? Do you or have you ever smoked, chewed, or vaped tobacco products?(Required)NoYesI quitIf yes, which type and how often?(Required) When did you quit?(Required) Do you or have you ever used any drugs?(Required)NoYesI quitIf yes, which type and how often?(Required) When did you quit?(Required) Do you do any form of regular exercise every day?(Required)NoYesIf yes, how much?(Required) DEPRESSION SCREENINGOver the past two weeks, have you felt down, depressed, or hopeless?(Required)NoYesOver the past two weeks, have you felt little interest or pleasure in doing things?(Required)NoYes FUNCTIONAL ABILITY/SAFETY SCREENDo you need help with the phone, transportation, shopping, preparing meals, housework, laundry, medications, or managing money?(Required)YesNoDoes your home have rugs in the hallway, lack grab bars in the bathroom, lack handrails on the stairs or have poor lighting?(Required) YesNoHave you noticed any hearing difficulties?(Required) YesNoNameThis field is for validation purposes and should be left unchanged.
