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Currency [0]/Explanatory TextG5Explanatory Text % 0Good;Good  a%1 Heading 1G Heading 1 I}%O2 Heading 2G Heading 2 I}%?3 Heading 3G Heading 3 I}%234 Heading 49 Heading 4 I}% 5InputuInput ̙ ??v% 6 Linked CellK Linked Cell }% 7NeutralANeutral  e%"Normal 8Noteb Note   9OutputwOutput  ???%????????? ???:$Percent ;Title1Title I}% <TotalMTotal %OO= Warning Text? Warning Text %XTableStyleMedium2PivotStyleLight16`C?Sheet1Sheet2PSheet3`i uPractice Name: Month/Yr: Random ID#:3. Dates Initial VisitRecentNextNo appt __/__/___5. Age: 6. Ethnicity W B A Haw/Pac AI/NA Other Unknown 7. ConditionsAsthma Afib C. Vasc DzCHFCOPDCADDementia D'pressionDM IDM IIHIV/AIDS HyperlipidHTNMalig OsteoarthOsteopor Overwt/Ob Renal Insf.Other: 8. Body HabitusOverwtObeseNDNLBMI:<2525-29.9>30YN 9. Smoking HxNeverCurrentFormerNot documented$11. Two forms of ID on each document'12. All forms in chart used (no blanks)13. Only one form in use 14. Labs/results initialed/dated15. Only forms for this patient16. Consents signedNA17. Condition of chart 1 2 3 4 5%18. Nursing/MA notes initialed/signed*19. Nursing/MA notes with prof designation Not signed%20. Ability to learn/preferred method&21. Documentation of patient education22. Assessment for pain#23. Advance directive or discussion24. Medication UTD with Rx medsNo Rx 25. Rx drugs with followed by:DosageForm FrequencyRoute (Skip if not on Rx meds)#26. Medication UTD with NON-Rx meds%27. Are following on summary sheet or$ standardized forms (maintained) AllergiesChronic ProblemsAcute problemsSurgical historyFamily HistorySHxHM ScreeningVax Hx#28. Compliance with NPSG Do Not Use29. Patient 11-1830. Adolescent Care ONLYMethod of family planningCounseled/Tested for HIV/AIDsRisk behavior assessment31. Woman 21+ years old32. PAP within 3 years?OtherRefused 33. Breast exam annually (40-69))34. If 52+ - was mammogram within 2 years35. DRE @ 50 (or 45) - Men Only36. Colon cancer screening37. CV Risk (all adults 18+)TobaccoObesityActivity Cholesterol*38. Risk factors for CAD or history of CAD$39. Last sys BP <140; last diast <90 Not recorded+40. If CAD, DM or Chol, last LDL <100 (24m)41. Antiplatelet medication Contraind."42. IF CAD & Hx of MI, betablocker Not eligible43. Diabetes mellitus IIDiabetes mellitus II ONLY <12 months&45. Two HbA1c in 1 year; 3 month apart46. Most recent HbA1c47. HbA1c control>9/= 10050. Antiplatelet medication51. ACE or ARB)52. Dilated retinal exam within 12 months&53. Monofilament exam within 12 months(54. Microalbuminuria test past 12 months55. History of CHF56. LVSD on ACE-I or ARB57. History of depression*58. Dx of new episode of major depression& "Antidepressant for entire 12 weeks 60. If 75+, assessment for falls'61. Within the past year, assessed for:Labililty or affectJudgment Orientation IntelligenceMemory!62. Documented in past 12 months:Vision evaluationHearing evaluationPhysical/Social Environ.Nutritional assessmtSx of urinary incontin.59. Patient 65+?)63. Annual influenza vax (when available)64. Pneumococcal vax65. Tetanus vax within 10 years10. Language other than English/If Risk Factors for CAD or History of CAD ONLY:44. Sys <140 AND Dia <80 M F4. 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