MEDICARE ANNUAL WELLNESS VISIT QUESTIONNAIRE
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1 PATIENT NAME: Date of Birth: MEDICARE ANNUAL WELLNESS VISIT QUESTIONNAIRE Today s Date: The Annual Wellness Visit is for preventative health and provided by Medicare. This is not a visit to evaluate new or ongoing medical problems, and does not cover the management of medical problems such as labs/prescriptions/etc. Should you need an appointment for a medical problem, a co-pay would be required and it would need to be scheduled as a separate appointment. Is this information provided by the patient? Yes No If not, who is providing the information? In general, how would you rate your current health? Excellent Very Good Good Fair Poor CURRENT MEDICINES AND MEDICAL CONDITIONS I don t take medications (if checking this box please continue on to page 2) During the past WEEK, how often did you forget to take or decide not to take one or more of your medications? Never Sometimes Usually Always How sure are you that you understand the reason why you take each of your medications? Very sure Somewhat sure Not very sure How confident are you that you can manage your medical conditions from day-to-day? Very confident Somewhat confident Not very confident page 1 of 5
2 ACTIVITIES OF DAILY LIVING In the past WEEK, have you needed help with any of the following activities? Using the toilet: Dressing: Getting in/out of chairs: Eating: Bathing: Making it to the restroom: Taking medications: Laundry/housework: Shopping: Managing money: Using the telephone: Preparing meals: Traveling: In the last YEAR, have you lost your urine and gotten wet? HEARING Do you have concerns about your hearing? If YES, would you like to schedule further evaluation of your hearing? MEMORY In the last MONTH, how often did you have trouble remembering/thinking clearly? Never Sometimes Usually Always FALLS Do you feel unsteady on your feet? Do you worry about falling? Have you fallen in the past YEAR? Number of times: Were you injured? Have you had dizziness in the last 6 MONTHS? Do you use any assistive devices for walking? If yes, which ones? Another person Railing/objects around the house Cane Walker Wheelchair Do you have scattered rugs in your home? EYESIGHT Because of your eyesight, do you have trouble driving a car, watching TV, reading, or doing daily activities? Last eye exam: page 2 of 5
3 HOSPITAL & ER VISITS During the past 6 MONTHS, how many times did you go to the emergency room? None 1 or more times Do you think you will go back to the emergency room again in the next 6 months? Not likely Possibly likely Very likely During the past 6 MONTHS, how many times did you stay in the hospital overnight as a patient? None 1 or more times Do you think you will go back to the hospital again in the next 6 months? Not likely Possibly likely Very likely PAST SURGERIES What surgeries have you had since your last wellness visit? EXERCISE In general, how many days do you exercise each week? days On days when you exercise, how long do you exercise? minutes How often do you do exercises to strengthen your arms and legs? days When you exercise, how intense is your typical exercise? Light (stretching/slow walking) Moderate (brisk walking) Heavy (jogging/swimming) Very heavy (fast running/climbing) HOME MEDICAL EQUIPMENT Do you use home medical equipment? Who do you receive your home medical equipment from? CAFFEINE USE Do you drink caffeine daily? If yes, how many servings per day? TOBACCO USE Please indicate your tobacco history: Current tobacco user packs per day cans per day Former tobacco user Quit date: Previously used: packs per day cans per day Never used tobacco ALCOHOL USE In a given week, how many days do you drink alcohol? days Do you ever drink more than 4 drinks in one sitting? page 3 of 5
4 OTHER DRUG USE Do you use any drugs for non-medical reasons? FAMILY HISTORY Have any of your immediate family members (parents, siblings, or children, living or deceased) had the following diseases?) Heart Attack Stroke Diabetes Cancer If yes, who and what type of cancer: LIVING SITUATION Who lives with you? If you live alone, who can you call if you need help? Contact Name: Contact phone number: Do you have any animals/pets? Type of pets: BARRIERS TO CARE Do you have any problems getting the care you need because of any of the following reasons? Affording medications Transportation/driving to appointments Increased stress in your life Other: VEHICLE SAFETY Do you always wear a seatbelt when driving? NUTRITION What type of diet do you follow? ACTIVITIES: What activities do you enjoy doing? PAST SCREENINGS / DATES: Colon Cancer Screening: Bone Density Screening: Mammogram: Lung Cancer Screening: Abdominal Aortic Aneurysm: PSA Screening: Tetanus Vaccine: Flu Vaccine: Pneumonia Vaccine: Shingrix Vaccine: page 4 of 5
5 DEPRESSION SCREENING: Over the last 2 WEEKS, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things Not at all Several days More than half the days Nearly every day Feeling down, depressed, or hopeless Not at all Several days More than half the days Nearly every day SPECIALTY PROVIDERS: Outside of The Family Health Centers, list all physicians/providers you currently see: Allergy: Cardiologist (Heart): Dermatology (Skin) : Gastroenterology (Stomach/Liver): Endocrinology (Diabetes, Thyroid): Head, Neck, and Ear: Nephrologist (Kidney): Neurology: OB/GYN: Oncology (Cancer): Ophthalmology (Eye Doctor): Physical Therapy: Podiatry (Foot): Pain: Pulmonology (Lungs): Rheumatology: Urology (Bladder): Other: ADVANCE DIRECTIVES Do you have a living will? If you haven t already, please bring a copy of your living will to the office at your convenience. Do you have a Durable (healthcare) Power of Attorney? If yes, who is it? page 5 of 5
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