Initial Preventive Physical Exam

At a minimum, collect this information:

• Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments)
• Current medications, supplements, and other substances the patient may be using
• Family history (review the patient’s family and medical events, including hereditary conditions that place them at increased risk)
• Diet
• Physical activities
• Social activities and engagement
• Alcohol, tobacco, and illegal drug use history

Learn information about Medicare’s mental health and substance use disorder (SUD) services coverage.

Depression risk factors include:

• Current or past experiences with depression
• Other mood disorders

Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. The American Psychological Association’s Depression Assessment Instruments has more information.

Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the patient’s:

• Ability to perform activities of daily living
• Fall risk
• Hearing impairment
• Home and community safety, including driving when appropriate

Medicare offers cognitive assessment and care plan services for patients who show signs of impairment.

Include:

• Measurement of height, weight, body mass index (or waist circumference, if appropriate), blood pressure, balance, and gait
• Visual acuity screen
• Other factors deemed appropriate, based on medical and social history and current clinical standards

End-of-life planning is verbal or written information about:

• The patient’s ability to prepare an advance directive in case an injury or illness prevents them from making their own health care decisions
• Whether you (their physician or practitioner) agree to follow their advance directive

This includes psychiatric advance directives.

For a patient with a current opioid prescription:

• Review any potential opioid use disorder risk factors
• Evaluate the patient’s pain severity and current treatment plan
• Provide information about non-opioid treatment options
• Refer the patient to a specialist, as appropriate

The HHS Pain Management Best Practices Inter-Agency Task Force Report has more information. Medicare now covers monthly chronic pain management and treatment services.

Include a brief written plan, like a checklist, for the patient to get:

• A once-in-a-lifetime screening electrocardiogram (ECG), as appropriate
• Appropriate screenings and other covered preventive services