4. ECP + Medwell

Comprehensive Evaluation and Medicare Wellness Questionnaire
Dear Patient,

You are scheduled for a full preventive care examination, otherwise knowns as an “Annual Wellness” or Physical Exam”. This type of visit includes a check of your height, weight, bloodwork, and vital signs and recommendations for preventative care and on-going health maintenance.

However, if you have new or acute symptoms that you want to address during this visit or have chronic conditions that need follow up, then it will also be billed as a problem-focused visit in addition to your preventative visit.

Your medical insurance plan likely covers preventative care visits differently than problem-focused visits, which may in turn affect your financial responsibilities, including co-payments or deductibles. We want you to be aware of these facts.

If you have any questions about this policy, please speak to one of the Patient Service Representatives at our Front Desk.

Sincerely,

Eileen Testa

Eileen Testa

Administrator
To ensure that our practice receives your form, please click the green "Submit" button below.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
My appointment is with: *
Appointment date:*

MonthDayYear
Date
Audit C
Audit-C Score:
PHQ-9
PHQ-9 Score:
Social Determinants of Health
Social Determinants of Health Score:
Medication Issues
Falls Risk
Pain Screening
ADLs
Urinary Incontinence
Advanced Directive
Flu Shot
What would you like to discuss with your provider today? *
Since you last saw the doctor, have you had any changes in any of the following areas?*

No New SymptomsConstipationDiarrheaChest PainShortness of breathNumbness or tinglingWeight gainWeight lossMoleRashJoint painBack painAnxietyDepression
Marital Status*

MarriedPartneredSingleSeparatedDivorcedWidowed
How many people live at home with you?*
Who lives with you?*

spouse/partnerno one else (live alone)kids/grandkidsotherparents
Emergency Contact*
Employment status*

EmployedRetiredStudentUnemployed
What is your occupation? *
Since your last visit with our office, were you admitted to the hospital?*

NoYes
Please list details for all recent admissions:*
Since your last visit to our office, have you had any new testing performed?*
Please add details for all tests performed*
Since your last visit to our office, have you developed any new allergies or had a bad reaction to a medication or food?*

NoYes
Please add all new allergies:*
Since your last visit to our office, have you seen a specialist*

NoYes
Please list all specialists you have visited recently:*
Since your last visit to our office, have you had any vaccinations? (shots)*
Please list all vaccinations*
Since your last visit to our office, have you started any new prescribed medications, over-the-counter medications, herbal medications or vitamins?*

NoYes
Please list each new medication*
Has anything changed with the health of your family members? (including parents, siblings, or children)*

NoYes
Please explain: *
If you smoke or chew tobacco or vape, have you thought about quitting? *

	No	Yes
Has anyone been concerned about your drinking of alcohol or use of drugs?
Do you have a gun in the home?
Have you had sex with more than one partner within the past year?
Have you ever been emotionally or physically abused by your partner or someone important to you?

Falls Risk
Have you fallen two or more times in the past year?*

NoYes
If yes, were you injured?*

NoYes

	No	Yes
Do you have difficulty with dizziness or problems with balance?
Do you avoid doing things due to the fear of falling?
Do you have things in your house which might cause you to fall?

Physical Activity and Pain

	Almost Never	Occasionally	Frequently
How often does physical or emotional health interfere with your daily activities?
How often do you take the escalator over the stairs?
How often does pain interfere with your normal activities?

On a scale of 0 to 10, (ten being strongest) how much pain do you have on a daily basis? *

0

1

2

3

4

5

6

7

8

9

10

0 is (No pain), 10 is
If you do have daily pain, where is the pain located? *
Approximately how many days each week are you physically active?*

0 - 1 days2 - 3 days4 or more days
How many days a week do you exercise?*

0 - 1 days2 - 3 days4 or more days
How many hours of sleep do you usually get each night?*

5 or less hours6 - 7 hours8 or more hours
Activities of Daily Living

	No	Yes
Do you need help eating, bathing, getting dressed, or getting around your home?
Do you need help preparing your own meals?
Do you need help doing your own housekeeping?
Do you need help with shopping?
Do you need help handling your own money?
Do you need help travelling by bus or taxi?
Do you need more help at home with your care or doing chores?

Do you drive a car?*

NoYes
If yes, do you have any difficulty driving?*

NoYes
When was your last dilated eye exam?
Other Health Issues

	No	Yes
Do you have problems with your hearing?
Do you have problems with your memory?
Do you have trouble eating well?
Do you have trouble with your teeth or dentures?

Have you had a flu shot this year?*

NoYes
If not, do you want a flu shot?*

NoYes
Do you have a living will or advanced directive?*

NoYes
If yes, have you given us a copy?*

NoYes
Bladder Control

	No	Yes
Is leaking of urine a problem for you?
Has urine leakage changed your activities or interfered with your sleep?

Medications
How often did you miss taking one or more of your medications in the last 2 weeks?*

NeverAlmost neverOccasionallyFrequentlyI do not take any medication

	No	Yes
Are you unsure or confused about what your medications are for?
Are you unsure or confused about how or when to take your medications?
Are you unsure or confused about why you need to take your medications?
Do you have any medications you cannot afford?
Do you have trouble getting your medications due to the inability to get to the pharmacy or have them delivered?
Do you have concerns or questions about your medication side effects?
Do you have difficulty taking medicine the way you are instructed?

Other Issues Affecting Your Health

	No	Yes
In the past year, was there a time when you could not afford to see a doctor?
Are you worried at times you cannot get your medicine due to expenses?
Do you ever eat less because there is not enough food?
Are you worried that in the next few months you may not have housing?
Do you feel your safety is threatened in your home?
In the past year, have you had a hard time paying your utility bills?
Do you feel like it is a hardship to obtain household supplies?
Do you have any problems with access to transportation to get to your medical appointments?
Do you need a translator to communicate with your provider?
Do you have difficulty learning about your medical condition from the information given to you or what is told to you?
Do you miss having people around you?

Do you receive enough support from family and friends?*

AlwaysUsuallySometimesNever
How confident are you that you can control and manage most of your health problems?*

VerySomewhatNot very confidentNot applicable
In the past 12 months, how often did you get an appointment in the amount of time you felt was appropriate?*

AlwaysUsuallySometimesNever
In the past 12 months, how satisfied are you with the care or treatment you received in this office?*

VerySomewhatNot very satisfiedNot applicable
Depression Screening (PHQ-9)

In the last 2 weeks how often have you had: *

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Little interest or pleasure than normal in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or feeling that you are a failure or that you have let yourself or family down
Trouble concentrating on things such as reading the newspaper or watching TV
Moving or speaking so slowly that other people could have noticed, or the opposite? (being so fidgety or restless that you have been moving around a lot more than usual)
Thoughts that you would be better off dead, or of hurting yourself in some way

Alcohol Screening
Did you have a drink containing alcohol in the past year?*

NoYes
How often did you have a drink containing alcohol in the past year?*

NeverMonthly or less2 - 4 times a month2 - 3 times a week4 or more times a week
How many drinks did you have on a typical day when you were drinking in the past year?*

1 or 23 or 45 or 67 to 910 or more
How often did you have 6 or more drinks on one occasion in the past year?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
Insurance Summary

It is a requirement of your insurance company that our practice have an updated copy of your insurance card annually.
Primary Insurance Payer
Member ID
Secondary Insurance Payer
Member ID
Are you the policy holder for this insurance?
If you answered No, please enter subscriber's information below.
Subscriber Information
Please upload images of your insurance card

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DISCLAIMER: The section below is to upload images of your insurance cards. If you are not using a mobile device, please skip the below section and bring your insurance cards to your appointment. Thank you
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HIPAA PRIVACY AUTHORIZATION FORM

NINTH STREET INTERNAL MEDICINE ASSOCIATES, INC.

Authorization for use or disclosure of protected health information. (Required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164)

Please list names and relationships of all persons that you authorize Ninth Street Internal Medicine Associates to release your medical information to during the course of your care:
First Name  Last Name     RelationshipPhone Number
First Name Last Name    RelationshipPhone Number
First Name Last Name  Relationship  Phone Number

I hereby authorize all medical sources to release and disclose the following protected health information to:

NINTH STREET INTERNAL MEDICINE ASSOCIATES

805 Locust Street

Philadelphia, PA 19107

Phone: 215-440-8681

Specific Information to be disclosed:
Entire Medical Record
Only period of events from:   Please describe
Other:   Please describe

The information for which I’m authorizing disclosure will be used for the following purpose:
Further medical care
Personal use
Other:   Please describe

Important Information About Your Rights:

I understand that my records are protected under the Health Insurance Portability and Accountability Act, Federal Privacy Act, P.L. 93-575, the Federal Alcohol and Drug Abuse Act, P.L. 92-282, the Pennsylvania Mental Health Procedures Act, 1976 and the Pennsylvania Confidentiality of HIV Related Information Act, and therefore cannot be disclosed without my written consent unless otherwise provided for in the regulations. Under the Mental Health Act, this authorization expires one (1) month from the date of my signature. Under the Federal Alcohol and Drug Abuse Act, this authorization shall become void ninety (90) days from the date of my signature. In addition, I understand that I may revoke this authorization (except to the extent that action has been taken in reliance thereon) at any time by written, dated communication to the Ninth Street Internal Medicine and/or that my consent expires under the circumstance above. I understand that once copies of my information are provided, NSIM cannot prevent re-disclosure by the recipient. I understand that any information disclosed in response to this request will NOT include information related to my treatment for AIDS/HIV, psychiatric care/treatment, treatment for drug/alcohol, unless I specifically consent to release of this information by checking any or all the boxes below:
AIDS/HIV Information
Psychiatric Care/Treatment
Treatment for Drug and Alcohol use/abuse
2025 HIPAA Privacy Authorization Form
NINTH STREET INTERNAL MEDICINE ASSOCIATES, INC.
Authorization for use or disclosure of protected health information. (Required by the Health Insurance Portability and Accountability
Act – 45 CFR Parts 160 and 164)

Please list names and relationships of all persons that you authorize Ninth Street Internal Medicine Associates to release your
medical information to during the course of your care:
NameRelationshipPhone
May we contact this person in case of an emergency?

YesNo
NameRelationshipPhone
May we contact this person in case of an emergency?

YesNo
NameRelationshipPhone
May we contact this person in case of an emergency?

YesNo
I hereby authorize all medical sources to release and disclose the following protected health information to:
Ninth Street Internal Medicine Associates
805 Locust Street, Philadelphia, PA 19107
Phone: 215-440-8681 - Fax: 215-440-9953
Specific information to be disclosed:

Entire Medical Record Only information related to(specify):Only the period of events from to(please describe): _________________________________Other: (please describe)
Specific information to be disclosed:
Entire Medical Record Only information related to (specify):
Only the period of events from to (please describe):
Other (please describe):
The information for which I’m authorizing disclosure will be used for the following purpose:

Further Medical CarePersonal Use
Other (please describe):
Important Information About Your Rights
I understand that my records are protected under the Health Insurance Portability and Accountability Act, Federal Privacy Act, P.L. 93-575, the Federal Alcohol and
Drug Abuse Act, P.L. 92-282, the Pennsylvania Mental Health Procedures Act, 1976 and the Pennsylvania Confidentiality of HIV Related Information Act, and therefore
cannot be disclosed without my written consent unless otherwise provided for in the regulations. Under the Mental Health Act, this authorization expires one (1)
month from the date of my signature. Under the Federal Alcohol and Drug Abuse Act, this authorization shall become void ninety (90) days from the date of my
signature. In addition, I understand that I may revoke this authorization (except to the extent that action has been taken in reliance thereon) at any time by written,
dated communication to the Ninth Street Internal Medicine and/or that my consent expires under the circumstance above. I understand that once copies of my
information are provided, NSIM cannot prevent re-disclosure by the recipient. I understand that any information disclosed in response to this request will NOT include
information related to my treatment for AIDS/HIV, psychiatric care/treatment, treatment for drug/alcohol, unless I specifically consent to release of this information
by checking any or all the boxes below:
AIDS/HIV InformationPsychiatric Care/TreatmentTreatment for Drug and Alcohol use/abuse
Signature of Patient Date of Birth
Printed Name of Patient Date of Signature
(Initial) I acknowledge that I have been provided a copy of Ninth Street’s Internal Medicine’s Notice of Privacy Practices explaining my rights and permitted uses and disclosures with regard to my protected health information.
(Initial) I acknowledge that this authorization is only good for one calendar year.
Name

First NameLast NameDOB
Click on the green "Submit" button below to send your answers to us. Thank you for taking the time to complete this form.
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	No	Yes
Medications
Bladder training exercises
Surgery

Comprehensive Evaluation and Medicare Wellness Questionnaire

Falls Risk

Physical Activity and Pain

Activities of Daily Living

Other Health Issues

Bladder Control

Medications

Other Issues Affecting Your Health

Depression Screening (PHQ-9)

Alcohol Screening

Insurance Summary

Please upload images of your insurance card

2025 HIPAA Privacy Authorization Form

NINTH STREET INTERNAL MEDICINE ASSOCIATES, INC.