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PATIENT NAME:Date of Birth:MEDICARE ANNUAL WELLNESS VISITQUESTIONNAIREToday’s Date:The Annual Wellness Visit is for preventative health and provided by Medicare. This is not a visitto evaluate new or ongoing medical problems, and does not cover the management of medicalproblems 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 NoIf not, who is providing the information ?In general, how would you rate your current health? Excellent Very Good Good Fair PoorCURRENT 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 oneor more of your medications? Never Sometimes Usually AlwaysHow sure are you that you understand the reason why you take each of your medications? Very sure Somewhat sure Not very sureHow confident are you that you can manage your medical conditions from day-to-day? Very confident Somewhat confident Not very confidentpage 1 of 5
ACTIVITIES OF DAILY LIVINGIn the past WEEK, have you needed help withany of the following activities?FALLSDo you feel unsteady on your feet? YES NOUsing the toilet: YES NODressing: YES NOGetting in/out of chairs: YES NOEating: YES NOBathing: YES NOMaking it tothe restroom: YES NOTaking medications: YES NO YESLaundry/housework: YES NOShopping: YES NOHave you had dizziness in the last 6MONTHS?Managing money: YES NO YESUsing the telephone: YES NODo you use any assistive devices for walking?Preparing meals: YES NO YESTraveling: YES NOIf yes, which ones?In the last YEAR, have you lost your urineand gotten wet? YES NOHEARINGDo you have concerns about your hearing? YES NOIf YES, would you like to schedule furtherevaluation of your hearing? YES NOMEMORYIn the last MONTH, how often did you havetrouble remembering/thinking clearly? Never Sometimes Usually AlwaysDo you worry about falling? YES NOHave you fallen in the past YEAR? YES NONumber of times:Were you injured? NO NO NO Another person Railing/objects around the house Cane Walker WheelchairDo you have scattered rugs in your home? YES NOEYESIGHTBecause of your eyesight, do you havetrouble driving a car, watching TV, reading,or doing daily activities? YES NOLast eye exam:page 2 of 5
HOSPITAL & ER VISITSHOME MEDICAL EQUIPMENTDuring the past 6 MONTHS, how many timesdid you go to the emergency room? None 1 or more timesDo you think you will go back to theemergency room again in the next 6 months? Not likely Possibly likely Very likelyDuring the past 6 MONTHS, how many timesdid you stay in the hospital overnightas a patient? None 1 or more timesDo you think you will go back to the hospitalagain in the next 6 months? Not likely Possibly likely Very likelyPAST SURGERIESWhat surgeries have you had since your lastwellness visit?Do you use home medical equipment? YES NOWho do you receive your home medicalequipment from?CAFFEINE USEDo you drink caffeine daily? YES NOIf yes, how many servings per day?TOBACCO USEPlease indicate your tobacco history: Current tobacco userpacks per daycans per day Former tobacco userEXERCISEIn general, how many days do you exerciseeach week? daysQuit date:Previously used:packs per daycans per dayOn days when you exercise, how long do youexercise? minutes Never used tobaccoHow often do you do exercises to strengthenyour arms and legs? daysALCOHOL USEWhen you exercise, how intense is yourtypical exercise?In a given week, how many days do you drinkalcohol? days Light (stretching/slow walking)Do you ever drink more than 4 drinks in onesitting? Moderate (brisk walking) Heavy (jogging/swimming) Very heavy (fast running/climbing) YES NOpage 3 of 5
OTHER DRUG USEBARRIERS TO CAREDo you use any drugs for non-medical reasons? YES NODo you have any problems getting the care youneed because of any of the following reasons? Affording medications Transportation/driving to appointmentsFAMILY HISTORYHave any of your immediate family members(parents, siblings, or children, living or deceased)had the following diseases?)Heart Attack YES NO Increased stress in your life Other:VEHICLE SAFETYIf yes, who:Do you always wear a seatbelt when driving?Stroke YES YES NOIf yes, who:Diabetes YES NO NONUTRITIONIf yes, who:What type of diet do you follow?Cancer YES NOIf yes, who and what type of cancer:LIVING SITUATIONACTIVITIES:What activities do you enjoy doing?Who lives with you?PAST SCREENINGS / DATES:If you live alone, who can you call if youneed help?Colon Cancer Screening:Contact Name:Bone Density Screening:Mammogram:Contact phone number:Lung Cancer Screening:Do you have any animals/pets?Abdominal Aortic Aneurysm: YESPSA Screening: NOType of pets:Tetanus Vaccine:Flu Vaccine:Pneumonia Vaccine:Shingrix Vaccine:page 4 of 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 dayFeeling down, depressed, or hopeless Not at all Several days More than half the days Nearly every daySPECIALTY PROVIDERS:Outside of The Family Health Centers, list all physicians/providers you currently see:Allergy:Oncology (Cancer):Cardiologist (Heart):Ophthalmology (Eye Doctor):Dermatology (Skin) :Physical Therapy:Gastroenterology (Stomach/Liver):Podiatry (Foot):Endocrinology (Diabetes, Thyroid):Head, Neck, and Ear:Nephrologist (Kidney):Neurology:Pain:Pulmonology (Lungs):Rheumatology:Urology (Bladder):Other:OB/GYN:ADVANCE DIRECTIVESDo you have a living will? YES NOIf 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? YES NOIf yes, who is it?page 5 of 5
MEDICARE ANNUAL WELLNESS VISIT QUESTIONNAIRE PATIENT NAME: _ 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.
