Monthly Wellness Check-In

Est. Completion Time: 60 to 90 Seconds
Section 1: Daily Health & Vitals Check

Please select "Yes" or "No" for the conditions you are currently managing and provide today's reading if applicable.

Group A (Therapy, Mobility, & Breathing — RTM)

    Chronic Back, Neck, or Joint Pain: [ ] Yes [ ] No | Pain Level (0-10): ____

    Arthritis or Limited Mobility: [ ] Yes [ ] No

    COPD, Asthma, or Shortness of Breath: [ ] Yes [ ] No | Used Inhaler Today? [ ] Yes [ ] No

    Functional Impact: Did your symptoms prevent you from doing your normal daily activities today? [ ] Yes [ ] No

Group B (Vitals, Heart, & General Health — CCM)

    High Blood Pressure (Hypertension): [ ] Yes [ ] No | Today's BP: ____/____

    Diabetes or High Blood Sugar: [ ] Yes [ ] No | Today's Sugar: ____

    Congestive Heart Failure / Heart Issues: [ ] Yes [ ] No

    Height & Weight Tracking: Height: [ ___ ft ___ in ] (Locks after first entry) | Today's Weight: [ ____ lbs ]

    Mental Health (Anxiety, Depression, Sleep): [ ] Yes [ ] No

Section 2: Recent Care & Hospitalizations

This helps us coordinate your care with your other doctors.

    Have you visited the Emergency Room or been discharged from a hospital since your last check-in? [ ] Yes [ ] No

    If Yes, what was the reason? ______________________________________________________

Section 3: Medication Reconciliation & Requests

This section helps the doctor update your treatment plan and justifies your Telehealth benefits.

1. Current Medication Status: "Are you currently taking your medications exactly as prescribed?"

    [ ] Yes

    [ ] No, I missed a dose

    [ ] No, I stopped taking them

2. Current Medications: "What medications are you taking right now? (Include dosage if known)."

    Medication: ______________________________________________________

    Medication: ______________________________________________________

    Medication: ______________________________________________________

3. Allergies: "Do you have any new drug allergies we should know about?" [ ] No [ ] Yes: ________

4. New Medication/Refill Request: "Do you need the doctor to order a refill or a new medication for a symptom today?"

    [ ] Refill

    [ ] New Medication Request

    [ ] No Changes Needed

5. Reason for Request: "What is the specific reason or symptom for this medication request?"

    __________________________________________________________________

Section 4: Your Telehealth & Program Benefits

    Telehealth Delivery: All care is provided via Telehealth. The smartphone and mobile service are provided at no charge to facilitate these services.

    Smartphone Return: If you disenroll, the phone must be returned (Free Shipping Provided) or you may switch to a cash-pay plan.

    Drug Plan: Includes a 23-month formulary benefit (up to 3 annual or 6 semi-annual refills). After 23 months, this becomes a cash-pay benefit at $6.24/month.

Section 5: Unified Program Consents

Please check all three boxes to authorize your care:

[ ] Consent to Telehealth & Coordinated Care (RTM/CCM)
I agree to receive all clinical services via Telehealth. I authorize my care team to monitor my data and coordinate my treatment. I understand these services are a benefit to improve my health and I authorize the release of necessary health information.

[ ] SMS, Communication, & TCPA Consent
I expressly consent to receive SMS text messages, automated calls, and emails from the provider regarding my care, refills, and updates. This consent applies to the number provided today, as well as any other numbers I provide to the provider in the future. I can opt-out at any time by replying STOP.

[ ] Smartphone, Drug Plan, & Equipment Agreement
I acknowledge the smartphone return policy and the 23-month drug plan terms. I understand that free return shipping is provided if I no longer wish to participate in the program.
Section 6: Financial & Hardship Certification

Select the ONE status that applies to you:

    [ ] I AM ON MEDICAID
    Per CMS regulations, my co-pays for these Telehealth and monitoring services are automatically waived.

— OR —

    [ ] FINANCIAL HARDSHIP CERTIFICATION (NON-MEDICAID)
    Under penalty of law, I certify my annual household income is below $40,800. I understand my co-pay is waived while I am under this threshold. I agree to notify the provider if my income increases, at which point a $20/month co-pay may apply.