MEDICARE ANNUAL WELLNESS VISIT QUESTIONNAIRE Patient Name DOB Enrolled in Medicare of last Annual wellness exam Providers and Suppliers of Your Medical Care Please list all providers and suppliers of your medical care such as primary care physicians, specialty physicians, chiropractors, pharmacies, herbalists and therapists. IF YOU USE OXYGEN PLEASE PROVIDE THE NAME OF SUPPLIER Primary Care Physician(s) Debra K. Higginbotham MD Specialty Family Medicine Other Patient Care Team members Specialty Medication Allergies Medication Reaction Your History Please check the appropriate box for the conditions as they apply to you
yes no yes no Medical History Condition Comments Condition Comments Condition comments Allergies Anemia Depression Diabetes Heart Attack (Myocardial infarction) Nerve/muscle disease Anxiety Emphysema Osteoporosis Arthritis Asthma Blood transfusion Cancer Cataracts Heart Failure (CHF) Clotting disorder Chronic obstructive lung disease (COPD) Reflux, Heartburn (GERD) Glaucoma Heart murmur HIV/AIDS High Blood Pressure (Hypertension) Kidney disease Meningitis Other Medical History / Injuries Seizures Sickle cell anemia Stroke Substance abuse Thyroid disease Tuberculosis Ulcers Surgical History Female Number of Pregnancies Number of live births
Surger y Appendectomy Brain Cosmeti c C- Section Joint replacement Small intestine Breast Eye Spine Gall Bladder (Cholecystectomy ) Fracture Tubal Ligation Colon Hernia repair Heart Valve Replacemen t Surgical History Male Appendectomy Brain Heart Bypass Gall Bladder (Cholecystectom y) Colon Other surgical history Cosmetic Eye Fracture Hernia repair Joint replaceme nt Prostate Small intestine Spine Heart Valve Replaceme nt Vasectomy
Alive Deceased Alcohol abuse Arthritis Asthma Cancer Type of Cancer Chronic Obstructive Depression Diabetes Drug Abuse Early Death Reason of Early Death Heart Disease High Hypertension Kidney Disease Mental illness Stroke Family History Please check the appropriate box of the conditions that apply to your blood relatives Relation Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Sister Brother Daughter Son Other Family Family history comments
Social History Sexually Active t currently Have you been tested for HIV / STDs If date of last screening Caffeine Use If number of drinks per day Alcohol Use If number of drinks per week Recreational Drug Use If number of times used per week If list type(s) of recreational drugs used Tobacco Use Never Smoked? Complete appropriate responses below Current Every day Smoker? Number of packs per day Number of Years Current Smoker?(not daily) Number of packs per week Number of Years Former Smoker? Quit date Passive Smoker? Are you ready to Quit? BEHAVIORAL RISK FACTORS PHYSICAL ACTIVITY How often do you typically exercise? (Check one) Regularly Infrequently I am currently not exercising
PSYCHOSOCIAL RISK FACTORS DEPRESSION Over the past 3 months, how often have you felt down, depressed, or hopeless? Almost all of the time A lot of the time Some of the time Almost never Over the past 3 months, how often have you felt a lack of energy? Almost all of the time A lot of the time Some of the time Almost never Over the past 3 months, how often have you felt little interest or pleasure in doing things? Almost all of the time A lot of the time Some of the time Almost never In general, how satisfied are you with your life? Very satisfied Satisfied Dissatisfied Very dissatisfied STRESS/ANGER Over the past 3 months, how often have you felt stress/anger? Never, rarely Occasionally Often Always
How well do you handle the stress/anger in your life? I m usually able to cope effectively At times I have problems coping I often have problems coping GENERAL WELL-BEING In general, would you say your health is? Excellent Very good Good Fair Poor Do you take any vitamins or supplements? SOCIAL/EMOTIONAL SUPPORT How often do you get the social and emotional support you need Always Usually Sometimes Rarely Never Visual Impairment Do you have any visual impairment? Explain Do you wear glasses? of your last eye exam Were you screened for Glaucoma?
Hearing Impairment Do you have any hearing impairment? Explain Do you wear hearing aids? HOME SAFETY Primary Residence Private Home (house, apartment, condo etc. ) Group Facility (Nursing home, Assisted Living) Homeless Do you live alone? Who would assist you in case of an emergency? Does your home have safety equipment? Circle all that apply grab bars shower chair bed rails Security alarm telephone smoke detectors emergency alert devices Does your home have any of the following? Throw rugs Stairs Uneven surfaces Other hazards Explain Does your home have adequate lighting? Do you have easily accessible neighbors?
Do you use a seatbelt when in a motor vehicle? FALL RISK ASSESSMENT Have you fallen in the past year? Details Do you feel unsteady when you walk? Do you feel dizzy when you get up from a bed or chair? ACTIVITIES OF DAILY LIVING Do you need assistance in walking, standing, sitting? Do you need assistance in eating, bathing, getting dressed or using the toilet? Do you need assistance with shopping or preparing meals? Do you need help with managing money or your medication? Do you need assistance in using the telephone?
Do you need assistance with transportation? In the past 3 months have you had difficulty with Sexual Issues Tiredness Incontinence Issues with mouth, teeth, or dentures ne of the above MEMORY LOSS Do family members report that you have difficulty remembering things? END OF LIFE PLANNING Do you have an Advance Directive, Living Will or Power of Attorney for Health Care (POA), in the case that an injury or illness causes you to be unable to make healthcare decisions? Would you like further information regarding Advance Directives? Patient signature If completed by someone other than the patient Print Name Signature Relationship to patient