874362 Rev. 01/2020
© 2020 Cigna
360 Comprehensive Assessment 2020
Member
First Name
DOB
(MM/DD/YYYY)
DOS
(MM/DD/YYYY)
Last Name
Member ID
PCP NPI
Rendering
Provider
Member's PCP
Location Source
Reason for Exam:
Past Medical History (this section intended only for
those conditions without an active treatment plan):
*Please note: All HEDIS QRS metrics are asterisked for your convenience
Surgical History:
*Medications: List all medications, including OTCs, with dosage and frequency. Or, attach printed, signed and dated list, and check here:
Allergies:
Difficulty taking or obtaining medication
Family History:
Father
Mother
Children
Siblings
Grandparents
HTN
Heart Disease
Stroke
Diabetes
Father Mother
Children
Siblings
Grandparents
High Lipids
Dementia
Depression
Cancer
Habits:
Tobacco Use:
Alcohol Use:
Alcohol usage a concern
for you or others?
Social
History:
Marital Status: Lives: High Risk for Sexually
Acquired Diseases
including HIV:
Social/Difficulty
handling finances:
Illicit Drug Use:
Current Physical
Activity as compared
to last year:
Mobility:
How is your memory compared to last year?
Difficulty with
bathing, toileting
and dressing?
Difficulty with
obtaining, preparing
or eating food?
Vision: Hearing: Speech:
Require glasses
/contacts for
routine vision
Hearing
issues /
hearing aid
Private Residence
PCP Practice
Facility
Patient
Other (name & relationship)
Reviewed and No Past Medical History
CVA with no residual effect
History of Cancer (specify):
Reviewed and No Surgeries
No Current Medications
Medications Reviewed/Reconciled
No known drug allergies
Reviewed and No Relevant History
Yes No
No
E-Cigarettes
Current Chew/Dip Use
Current Smoker, PPD
Previous Smoker, Year quit
Yes, Drinks per day
Yes No
Yes NoNoYesNoYes
Single
Married
Divorced
Domestic Partner
Widowed
Alone
Spouse
Institutional
Family
Other:
More
Less
Same
Independent
Wheelchair
Bedbound
Walker
Transfer
difficulty
Cane
No
Yes
No
Same
Yes
Normal
Normal
Normal
Impaired
Form 360 Page 1 of 7
Worse
Better
Prior organ transplant (specify site/organ):
Annual 360 Comprehensive Assessment
Other
Unknown History
Difficulty driving ?
NoYes
874362 Rev. 01/2020
© 2020 Cigna
*Fall Risk Screening: (mark all that apply)
Unable to perform exam b/c of
Diagnoses (3 or more existing)
Prior history of falls within 3 months
Incontinence
Visual Impairment
Impaired functional mobility
Environmental Hazard
Polypharmacy
Pain affecting level of function
Cognitive Impairment
TOTAL number of boxes marked
Fall Risk (4 or more reported)
Depression Screening (18 + y/o)
Have you felt depressed or down-and-out over the past 2 months?
Have you had a loss of interest in things that normally bring you pleasure?
Have you felt fatigued or had a loss of energy recently?
If two or more "Yes" then complete PHQ-9 document, and attach results to the 360 form:
*Urinary Incontinence Screening
During the last 3 months - have you leaked urine (even a small amount)?
If Yes, please distribute education material
Screening not performed because the patient is unable to communicate/answer.
Positive/Findings
Negative
Review of Systems
General
Cardiac
Respiratory
Gl
Musculoskeletal
Neurological
Skin
Psychiatric
Endocrine
Hematological
GU
HEENT
No
Yes
NoYes
No
Yes
PHQ-9 form
/Standard Screening Tool/Clinical Interview
PHQ-9 total score:
Pain treatment plan: if no pain = N/A
*Pain Screening
*Please assess the overall pain presence in the patient's day-to-day life:
(all patients should have pain addressed, if no pain = 0, has pain = 1 - 10)
0 1 2 3 4 5 6 7 8 9 10
Meds
Education
Pain doctor
PT
N/A
Other
RightLeft
5. Complications due to diabetes: (check all that apply)
4. Test for neuropathy:
Posterior Tibial
Dorsalis pedis
3. Check for foot pulse:
2. Look at both feet:
1. Ask the patient:
Foot Exam: (Complete for diabetic patients and/or patients with neuropathic complaints)
Weak Absent
Normal
Weak
Absent
Normal Abnormal
Normal
RIGHT LEFT
Key:
+ = Sensation
= No Sensation
Absent
Absent
Weak
Weak
Normal
Normal
Left Monofilament Right Monofilament AbnormalNormal
None of these
UlcerPeripheral neuropathy Peripheral vascular disease Gangrene Amputation: date, side & level:
Infection
Ulceration Skin breaks
Calluses or corns
Foot deformity
Nail disorders
None of these
Burning, tingling, numbness in feet
Pain or cramping in calf area during exercise
Previous foot ulcer
Yes No
None of
these
Form 360 Page 2 of 7
//
DOS:
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DOB:Member Name:
THIS SECTION SHOULD NOT INCLUDE AN ACTIVE DIAGNOSIS.
874362 Rev. 01/2020
© 2020 Cigna
Form 360 Page 3 of 7
Vitals:
*Ht (in): *Wt (lbs): *BMI:
Temp (F
0
):
*BP:
/
HR: RR: Gender:
Male
Female
Deferred
Deferred
Deferred
General
Comprehensive
Exam
Normal
Neck
Heart
Lungs
Breast
Abdomen
Extremities
GU
Musculoskeletal
Neurological
Skin
HEENT
Psychiatric
Hematologic
Lymphatic
Abnormal/Findings (check box [norm] or abnormal exam for each [except deferred] required)
Treatment Plan:
Cardiovascular:
Current Conditions:
Reviewed and No Active Disease Meds Monitor
Diet Labs
Referral
. .
Referral
LabsDiet
MonitorMeds
Reviewed and No Active Disease
Nutritional/Metabolic/Endocrine:
w/o Pacemaker
Persistent
Left
Systolic & Diastolic
Permanent
Right
Systolic
Primary Secondary
Mixed
Other (specify):
w/ Pacemaker
Chronic
Side:
Diastolic
CAD w/Angina Pectoris
Tachycardia
Sick Sinus Syndrome:
Atrial Fibrillation
Carotid artery stenosis
Hyperlipidemia If no statin, name of med
CHF:
Cardiomyopathy Type (specify):
CAD
Angina Pectoris
Myocardial infarction
w/o CHF
w/CHF(note: add specific CHF above)
HTN heart disease w/o CHF
Other Diagnosis (specify):
Peripheral Artery Disease
Hypertensive Heart and CKD (note: add specific stage of CKD to renal section)
Hypertensive CKD (note: add specific stage of CKD to renal section)
HTN heart disease w/CHF (note: add specific CHF above)
*Hypertension: Date of Diagnosis:
Presence of Internal Cardiac Defib
Other Diagnosis (specify):
Hyperthyroidism
Hypothyroidism
Pre-diabetes
Obesity (BMI 30 - 39.9)
Acquired (post surgical)
For BMI 35.0 - 39.9, document co-morbidity (i.e. HTN &/or DM
)
Moderate Mild Protein Calorie Malnutrition
Vascular Disease
//
DOS:
//
DOB:Member Name:
Type (specify):
Valvular disease
Overweight (BMI 25.0 - 29.9)
Left sided
Right sided
Morbid Obesity (BMI > 40)
Date:
Pulmonary Hypertension
Vessel(s):
native
graft
Aortic
Pulmonic
Tricuspid
Stenosis
Regurgitation
Mitral
Non-Rheu
Rheu
Abd Aortic Aneurysm
Thoracic Aortic Aneurysm
Cachexia
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© 2020 Cigna
Form 360 Page 4 of 7
Diabetes Mellitus: document all co-morbid manifestations
Reviewed and No Active Disease
DM: Type 1 Type 2
DM w/ Secondary Kidney Complications: CKD (note: include stage in renal section) Nephropathy
DM w/ Secondary Neurological Complications: Mononeuropathy
Polyneuropathy
Other:
Gastroparesis
Meds Monitor
Diet Labs
Referral
ReferralLabsDietMonitorMeds
Referral
LabsDiet
MonitorMeds
Referral
LabsDiet
MonitorMeds
Side:
Right
Left
Severe
w/ Macular Edema
Cataract
Mild
Proliferative
Retinopathy:
DM w/ Secondary
Ophthalmic Complications:
Moderate
Non-proliferative
Glaucoma
Location (specify): Non-Pressure Chronic Ulcer
DM w/ Secondary Skin Complications:
w/o Gangrene
Peripheral Angiopathy/PVD DM w/ Secondary Circulatory Complications:
w/ Gangrene
Right Left
Side:
DM w/ Oral Complications: Periodontal Other:
DM w/arthropathy:
Neuropathic Other:
Hyperglycemia Hypoglycemia DM w/ Other Secondary Complications:
Mixed Mucopurulent Simple Obstructive
w/ Oxygen Dependence
Centrilobular Panlobular
Mesothelioma
Location:
Unilateral
Other:
Emphysema:
COPD:
Chronic Bronchitis:
Respiratory:
Other Diagnosis (specify):
Tracheostomy
Pulmonary Fibrosis
Sarcoidosis
Obstructive Sleep Apnea
w/ Exacerbation
Bronchiectasis:
Asthma: Chronic Obstructive Severe Moderate Mild Persistent Intermittent
w/ Acute Lower Respiratory Infection
Asbestosis
Chronic Respiratory Failure
Osteoporosis Location(s):
Osteopenia Location(s):
Osteoarthritis Location(s):
Psoriatic Arthritis
Systemic Lupus Erythematous
*Rheumatoid Arthritis; Last DMARD Rx fill date
Reviewed and No Active Disease
Musculoskeletal:
Other Diagnosis (specify):
Location: S/P Amputation
Side:
Right
Right
Right
Left
Left
Left
Side:
Side:
Left Right
Left Right
Type: Senile Postmenopausal Unspecified
Yes
No
Has the patient had a fracture in the past 12 months?
If a fracture occurred, note specific bone location:
*Last Bone Density:
Yes No
Other Diagnosis (specify):
Both Left Right Location (specify): Non Pressure Ulcer:
Unstageable Stg 4 Stg 3 Stg 2 Stg1 Pressure Ulcer:
Skin/Subcutaneous:
w/Exacerbation
Reviewed and No Active Disease
Insulin Oral meds
Reviewed and No Active Disease
//
DOS:
//
DOB:Member Name:
If no DMARD document rationale
Diabetes w/osteomyelitis
Name of rheu arthritis med
Bisphosphonate medication
Start Date of Osteoporosis medication:
Denosumab Yes
No
874362 Rev. 01/2020
© 2020 Cigna
Form 360 Page 5 of 7
Renal/Urinary:
Chronic Kidney Disease (CKD)
CKD unspecified
Meds
Monitor Diet Labs Referral
Erectile dysfunction
Secondary hyperparathyroidism of renal origin
ReferralLabsDietMonitorMeds
*Urine Microalbumin Result: Date: eGFR:
ReferralLabsDietMonitorMeds
AV Fistula: Graft Catheter
No Yes Dialysis: ESRD
Stage 5 (GFR< 15)
Proteinuria (note: CKD 1 & 2 must have abnormal structural test, i.e. micro-albumin)
Stage 4 (GFR 15-29)
Stage 3 (GFR 30-59)
Stage 2 (GFR 60-89)
Stage 1 (GFR>90)
(Provided GFRs need to be consistent for more than a 3 month period)
ReferralLabsDietMonitorMeds
Reviewed and No Active Disease Gastrointestinal:
Reviewed and No Active Disease
Non-Alcoholic Alcoholic
Ileostomy
w/o Diarrhea w/ Diarrhea
G Tube
Other Diagnosis (specify):
Chronic Hepatitis - specify type:
J Tube
IBS
Ulcerative Colitis, if complications exist specify
Crohn's Disease location(s):
GERD
Colostomy
End stage liver disease
Cirrhosis liver:
Pancreatitis (chronic):
Other Diagnosis (specify):
Cystostomy
Urge Stress Unspecified
w/o LUTS w/ LUTS (specify):
BPH
Urinary Incontinence (check one):
Left
Left
Right
Right Side:
Side:
Nonexudative
Other Diagnosis (specify):
Exudative
Legal Blindness
Macular Degeneration
Glaucoma
Cataract
Senile
Reviewed and No Active Disease Eye:
Metastatic and if so, to what site(s)?
Left Right If Ductal Carcinoma in situ
Hormonal therapy
Date:
Date:
Radiation
Left
Chemo
Right
Mastectomy:
Neoplasm breast site
Treatment:
Breast Cancer
Metastatic and if so, to what site(s)?
Radiation Chemo Colectomy Date:
Colon Cancer
Reviewed and No Active Disease
Active Neoplasm/Blood Disorders and Current Treatment:
Other Malignancies (specify):
Melanoma in Situ (site):
Skin Cancer (type and site):
Metastatic and if so, to what site(s)?
Radiation
Other:
Chemo
Lower Lobe
Pneumonectomy
Upper Lobe L
Lobectomy
R
Treatment:
Lung Cancer
Metastatic and if so, to what site(s)?
Treatment:Prostatectomy
Prostate Cancer
Active Neoplasm/Blood Disorders and Current Treatment: Continued on Next Page
DOS: DOB:Member Name:
////
UnilateralBilateral
Left Right
Left
Right
874362 Rev. 01/2020
© 2020 Cigna
Form 360 Page 6 of 7
ReferralLabsDietMonitorMeds
Referral
LabsDietMonitorMeds
Relapse In Remission Current
Drug-induced Neutropenia (specify drug):
Multiple Myeloma
Myelodysplastic Disease
Other Diagnosis (specify):
AIDS HIV+
General Iron
Other:
B-12
Drug - induced (specify drug):
Sickle Cell
Due to Chemotherapy
Due to CKD Anemia:
Lower Limb
Right Left
Right Left
Right Left
Right Left
Lower Limb
Right Left
Upper Limb
Non-dominant
Non-dominant
Non-dominant
Non-dominant
Upper Limb
Non-dominant
Dominant
Dominant
Dominant
Dominant
Dominant
Other:
Speech/Language
Dysphagia
Cognitive (specify):
Monoplegia
Hemiplegia/Hemiparesis
History of Trauma
Weakness
Hemiplegia/Hemiparesis
Monoplegia
Specify late effect:
CVA w/ Sequlae: (note: specify below)
Reviewed and No Active Disease
Neurological:
Psychiatric:
Reviewed and No Active Disease
Mild Major If Major: Mild Moderate Severe
Partial Remission Full Remission Recurrent Single Episode
w/ Psychotic Symptoms (consider psych referral if s/sx presents, recurrent, or suicidal)
w/o Psychotic Symptoms
w/o Psychotic features w/ Psychotic features
Partial ) Full In Remission ( Current Bipolar
Anxiety
If Severe:
If Major:
Depressive Disorder
w/ Behavioral Disturbances w/ Dementia
Seizure Disorder (Epilepsy)
Other Diagnosis (specify):
Seizures
Parkinson's Disease:
Polyneuropathy other than due to diabetes, specify
ALS
Myasthenia gravis
Multiple Sclerosis
Quadriplegia
Other Diagnosis (specify):
In Remission Specify:
Dependence
Sbst. Abuse
Substance Use
In Remission
Alcohol Dependence Alcohol Abuse Alcohol Use
Other (specify): Disorganized
Undifferentiated Simple Paranoid Schizophrenia
Severe Moderate Mild Current severity:
Mixed Manic Depressed Current type:
Dementia:
Alzheimer's disease:
Unspecified Vascular
w/ Delusions w/ DepressionSenile
Early Onset Late Onset
w/ Dementia w/ Dementia and Behavioral Disturbance
Aphasia
ReferralLabsDietMonitorMedsActive Neoplasm/Blood Disorders and Current Treatment (Continued)
//
DOS:
//
DOB:Member Name:
Tobacco dependence
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:
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