LVFPA MEDICARE WELLNESS QUESTIONNAIRE Welcome to Medicare Visit/IPPE Annual Wellness Visit LIST OF PROVIDERS: Please provide a list of any other physicians or providers you see VACCINATIONS: Please list the most recent dates for the following vaccines. o Annual Influenza Date o Hepatitis B Date o Pneumonia Vaccine Date o Tetanus- Diphtheria-Pertussis Date o Tetanus-Diphtheria toxoid Date o Shingles Vaccine/ Zostavax Date o Any other vaccinations you have received with dates SCREENING TESTS: Please provide the most recent dates that you have completed the following tests and providers as applicable o Colonoscopy Date o Fit Cards/Occult Blood Stool testing Date o Sigmoidoscopy Date o Mammogram Date o DEXA/Osteoporosis Screen Date o Diabetic Foot Exam Date o Eye Exam Date o Prostate Specific Antigen Measurement Date o MEDICAL HISTORY o Emergency room or Urgent Care Visits o Hospitalizations
o Recent illnesses or injuries o Please check any of the following medical conditions that you have High Cholesterol Arthritis Asthma COPD High Blood Pressure Diabetes Stroke Heart Attack Atrial Fibrillation Depression Anxiety Pneumonia Osteoporosis Blood Clot Fracture Thyroid Disease Skin Cancer Colon Cancer Breast Cancer Lung Cancer Prostate Cancer Cataracts Glaucoma Heart Failure GERD Anemia Back pain o Please list any other medical conditions or diseases you have SURGICAL HISTORY o Please list all surgeries you have had SOCIAL HISTORY
o What race and/or ethnicity do you identify with? o Do you have a religious affiliation? If so, please list. o Are you married or in a relationship? o Do you have children? o Who do you live with? o Do you have support from family or friends? o Do you have a durable power of attorney? If so, what is your designated power of attorney s name and relationship to you? o Are you employed? o Do you have financial concerns? o Do you have any pets? o Do you currently drive?
o Do you wear a seatbelt when in a car? o Do you exercise? If so, what type and how often? o Do you drink alcohol? If so, how much and how often? Yes; Amount: o Do you currently or have you in the past used any drugs not prescribed by your doctor? o Do you currently smoke tobacco? If so, how many packs per day? Yes; PPD: o Do you have a history of smoking? If so, how long did you smoke and when did you quit? Yes; Years Smoked: Quit Date: o Do you have a history of, or currently use other forms of tobacco? FAMILY HISTORY o Please list any known medical problems in the following family members o Father o Mother Siblings o Children MEDICATIONS
o Please list all prescription medications, supplements, and over the counter medications with dosages HEALTH RISK ASSESSMENT o How would you rate your overall health? Excellent Good Fair Poor o How would you rate your physical health compared to last year? Better Same Worse o How would you rate your emotional health compared to last year? Better Same Worse o How would you rate your eyesight compared to last year? Better Same Slightly worse Much worse o How would you rate your hearing compared to last year? Same Slightly worse Much worse o How would you rate your overall pain in the past 7 days? ne Some A lot o Have you had problems with incontinence (loss of urine)? NUTRITION ASSESSMENT Nutrition Screening Initiative from AAFP, ADA, NCA o Do you have an illness/condition that has forced you to change the kind or amount of food you eat? Yes (2pts) o Do you eat fewer than 2 meals per day? Yes (3pts) o Do you eat few fruits, vegetables, or milk products? Yes (2 pts)
o Do you have 3 or more drinks of beer, liquor, or wine almost every day? Yes (2pts) o Do you have tooth or mouth problems that make it hard to eat? Yes (2 pts) o Do you always have enough money to buy the foods that you need? Yes (4pts) o Do you eat alone most of the time? Yes (1pt) o Do you take 3 or more medications or over the counter drugs daily? Yes (1 pt) o Have you lost or gained 10 pounds without trying in the last 6 months? Yes (2pts) o Are you not always physically able to shop, cook, or feed yourself? Yes (2pts) TOTAL POINTS IN YES COLUMN 0-2 Good, recheck in 6 months 3-5 Moderate Nutritional Risk, recheck in 3 months. 6+ High Nutritional Risk HEARING ASSESSMENT- HHIE-S o Does a hearing problem cause you to feel embarrassed when you meet new people? o Does a hearing problem cause you to feel frustrated when talking to members of your family? o Do you have difficulty hearing when someone speaks in a whisper? o Do you feel handicapped by a hearing problem?
o Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? o Does a hearing problem cause you to attend religious services less often than you would like? o Does a hearing problem cause you to have arguments with family members? o Does a hearing problem cause you to have difficulty when listening to TV or radio? o Do you feel that any difficulty with your hearing limits/hampers your personal or social life? o Does a hearing problem cause you difficulty in a restaurant with relatives or friends? TOTAL (Score >8 would benefit from further evaluation) HOME SAFETY ASSESSMENT- CDC STEADI Initiative o If you have small rugs, are they tacked down or slip resistant? o Are your stairs well lit, and have handrails? o When you use a step stool, is it sturdy with a handrail? o Are your exits, halls, stairways, and pathways kept clear and well lit?
o Do your bathtubs and showers have grab bars and nonskid surfaces? o Do you use a shower chair? o Do you have difficulty getting on and off the toilet? o Is the path from your bedroom to the bathroom well lit? o Do you have a working telephone to call for emergency help? o Do you know about Life Line? o Do you have smoke detectors that are checked twice a year? o Do you have a fire extinguisher available? ACTIVITIES OF DAILY LIVING- Katz o Are you able to bathe yourself, or need assistance bathing only a single part of body (example: your back or feet)? Yes (1 pt) (0 pts) o Are you able to dress yourself without assistance? Yes (1 pt) (0 pts) o Are you able to toilet yourself without assistance? Yes (1 pt) (0 pts)
o Are you able to transfer yourself without assistance? (Example from bed to standing, from bed to chair) Yes (1 pt) (0 pts) o Do you have complete control over your continence? (bowel and bladder control) Yes (1 pt) (0 pts) o Are you able to feed yourself without assistance? Yes ( 1pt) (0 pts) TOTAL (6= very independent, 0=very dependent) INSTRUMENTAL ACTIVITIES OF DAILY LIVING-Lawton For each category, choose the one statement that most closely corresponds to your functional ability for each task A. Ability to use Telephone Operates telephone independently, looks up, dials numbers (1 point) Can only dial a few well known numbers (1 point) Can answer telephone but cannot dial (1 point) Does not use telephone at all (0 points) B. Shopping Takes care of all shopping needs independently (1 point) Can shop independently for small purchases, or needs to be accompanied, or is completely unable to shop (0 points) C. Food Preparation Plans, prepares, and serves meals independently (1 point) Can prepare meals if provided with ingredients, can heat and serve prepared meals, or needs all meals prepared and served (0 points) D. Housekeeping Can maintain all heavy housework alone or with only occasional assistance (1 point)
Can perform light daily tasks such as dish washing and bed making (1 point) Can perform light tasks but cannot maintain cleanliness (1 point) Needs help with all home maintenance tasks (1 point) Does not participate in any housekeeping tasks (0 points) E. Laundry Does laundry independently (1 point) Launders small items such as socks, stockings (1 point) All laundry done by others (0 points) F. Transportation Drives a car or takes public transportation independently (1 point) Can take taxi but does not use other transportation (1 point) Travels assisted on public transportation (1 point) Travels only with assistance or does not travel (0 points) G. Medications Takes medications correctly independently (1 point) Can take medications if prepared in dosages in advance by others, or is not capable of dispensing own medication (0 pts) H. Finances Manages own finances or uses only occasional help (1 point) Incapable of handling own money (0 points) TOTAL (0=Dependent, 8=Independent) FALL RISK ASSESSMENT- CDC STEADI Initiative o Have you fallen in the past year? If yes, how many times? Were you injured?
Yes o Do you feel unsteady when standing or walking? o Do you worry about falling? YES to any question, evaluate gait/strength/balance with Timed Get Up and Go MOOD ASSESSMENT- PHQ-2 o Do you feel down depressed or hopeless? t at all (0) Several days (1) More than half the days (2) Nearly every day (3) o Do you have little interest or pleasure in doing things? t at all (0) Several days (1) More than half the days (2) Nearly every day (3) If positive answer to any question, administer PHQ-9 or Geriatric Depression Scale