874362 Rev. 01/2020
© 2020 Cigna
Form 360 Page 7 of 7
Anticonvulsants (Phenobarbital, Carbamazepine, Phenytoin, Valproic acid):
Preventive Medicine: (Please Use "D" if patient declines, N/A, "S" for scheduled, or "A" for advised)
Date
Result:
Result:
Result:
Long Term Medication Monitoring (Annual)
Reviewed
*Patients diagnosed with Diabetes:
*HbA1C:
*Microalbuminuria: Date
*Retinal Eye Exam: Date
*Name of Eye Care Provider:
Opioid Evaluation:
Patients diagnosed with COPD:
Patients diagnosed with CHF and/or CAD:
Serum Drug Concentration:
NoYes
NoYes
Result:
ACE or ARB Prescribed:
Beta Blocker Prescribed:
LVEF Assessment Date:
Describe
Other
Referral
Labs Diet Monitor Meds
SELECT TREATMENT PLAN
DIAGNOSES
Please list any diagnoses, not already noted under current conditions, which affect patient care, treatment or management.
COORDINATION OF CARE (Please list any providers/specialists involved in the patient's care and any supplier of equipment):
PLAN:
None
HMR reviewed and updated on today's visit?
BEHAVIORAL HEALTH REFERRAL:
CASE MANAGEMENT REFERRAL:
No
Yes
NoYes
No
Yes
Care Coordination
If Yes, please specify:
Social Concerns Patient Education Other (specify):
Indication:
I discussed the following with my patient:
OTHER COMMENTS:
Patient Email (OPTIONAL)
Tobacco cessation and education
*Urinary incontinence *Physical Activity
*Fall risk prevention
Other (specify):
Diet Modification 90 Day Rx FillHigh Risk Medications
PA NP DO MD
DO MD
SUPERVISING
PHYSICIAN NAME:
(if applicable)
DATE:
SUPERVISING
PHYSICIAN SIGNATURE:
(if applicable)
DATE:
RENDERING SIGNATURE:
RENDERING NAME:
Spirometry:
Beta Agonist/Anticholinergic Prescribed:
Is the patient on a statin?
No
Yes
Has your patient required/used more than a 15 day supply of narcotic medica-
tion over the last 12 months for a non-terminal diagnosis?
No
If Yes, are there alternative options besides opioids for the
patient's pain?
Yes No
Yes
//
DOS:
//
DOB:Member Name:
Date:
Date:
No
Yes
Abnormal
Normal
*Osteoporosis Screening (67-85) y/o): Date:
Sigmoidoscopy (Every 5 yrs), Date:
*Colorectal Cancer Screening FOBT (Annual test b/t 50-75 yo), Date:
Colonoscopy (Every 10 yrs), Date:
*Influenza Vaccine (65+y/o): Date:
*Mammogram (52-74 y/o, every 27 mo.): Date
Pneumococcal Vaccine (65+y/o)
Date Given:
Immunization(s) not carried out due to:
Prevnar (65+y/o) Date Given:
Living Will Advanced DirectiveDiscussion held Medical Power Of Attorney*Advanced care planning: Date
RESULT:
Stool DNA [Cologuard] (Every 3 yrs), Date:
CT Colonography (Every 5 yrs), Date:
Organ Donor
(guidelines recommend giving each
pneumococcal vaccine one year apart)
RENDERING NPI:
Shingles Vaccine: Date:
No
Yes
Statin Prescribed:
