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ANNUAL WELLNESS VISIT QUESTIONNAIRENAMEBIRTHDATEPRIMARY PROVIDERAPPT DATECURRENT PROVIDERS AND SUPPLIERS(i.e. Provider – Cardiologist; Supplier – Pharmacy, Oxygen, DME)Provider NameOver the last 2 weeks, how often have you been bothered by any of the following problems?(Circle your answer)Not atall1. Little interest or pleasure in doing things2. Feeling down, depressed, or hopeless00SeveralDays11Morethanhalf thedays22Nearlyeveryday33If you marked a 2 or 3 on either of the above questions PLEASE COMPLETE THE OTHER SIDEOF THIS FORMCURRENT MEDICATIONS:[ ] Reviewed and verifiedDRUG ALLERGIES/DRUG SENSITIVITIES:[ ] Reviewed and verifiedPAST SURGERIES:[ ] Reviewed and verifiedPAST HOSPITALIZATIONS:[ ] Reviewed and verifiedFAMILY HISTORY:[ ] Reviewed and verifiedScan in Medicare Annual Wellness Folder as: MM/DD/YYYY Annual Wellness Visit Questionnaire
04/29/2011; 5/16/11, revised 01/30/18, updated 2/19/2018-tls, updated 3/30/2018-tls, updated 3/8/2019al
Social and Safety QuestionnaireDo you use tobacco?If yes, How many years?Who do you live with?Married/ Single/ Divorced/ WidowedAre you exposed to second hand smoke?What is your highest level of education?Do you use any recreational drugs?What are your ow many per day?Do you exercise?Do you have any pets?Are you sexually active?If yes:with:Male FemaleBothDo you wear your seatbelt?Do you feel safe at home?Do you drink caffeine?What is your religion?Do you have any guns in the home?Do you have any financial concerns?In general, how would you rate your overall physical health?In the past 6 months, have you been bothered by leaking of urine?In general, how would you rate your overall mental or emotionalhealth?Have you had any falls in the last year?If so: How many falls?Any Injuries?Do you need help with preparing meals?Do you need help with transportation?Do you need help with shopping?Do you need help with taking medicine?Do you need help with managing finances?Do you need help with other activities or daily living?Do you live aloneDo you have any throw rugs in your home?Do you have poor lighting in your home?Do you have a slippery bathtub/shower?Does your home have grab bars in the bathroom?Does your home have handrails on stairs or steps?Do you have working smoke alarms in your home?Do you have trouble hearing the television or radio?Do you strain or struggle to hear/understand conversations?Do you have an Advance Directive?On file?Scan in Medicare Annual Wellness Folder as: MM/DD/YYYY Annual Wellness Visit Questionnaire
04/29/2011; 5/16/11, revised 01/30/18, updated 2/19/2018-tls, updated 3/30/2018-tls, updated 3/8/2019al
PERSONALIZED HEALTH PLANNAME:DATE OFBIRTH:Preventive screen (frequency)CoverageBone Mass Measurements (every 24 months)Medicare patients at risk for developingOsteoporosisCardiovascular Screening Blood Tests(every 5 yrs)– Lipid panel– Cholesterol– Lipoprotein– TriglyceridesAll asymptomatic Medicare patientsColorectal Cancer Screening– Flexible sigmoidoscopy (4 years, or once every 10years after a screening colonoscopy– Screening colonoscopy (every 24 months at highrisk; every 10 years not at high risk)– Fecal occult blood test (annually)– Barium enema (every 24 months at high risk; every 4years not at high risk)– Cologuard (every 3 yrs)– Medicare patients age 50 and up– Screening colonoscopy: Those at highrisk; no minimum age– No minimum age for having abarium enema as an alternative to a highrisk screening colonoscopy if thepatient is at high riskDiabetes Screening Tests (2 screening tests per year)Medicare patients with certain riskfactors for diabetes or diagnosed withpre-diabetes (patientspreviously diagnosed with diabetesaren’t eligible for benefit)Diabetes Self-Management Training (DSMT) andMedical Nutrition Therapy (Up to 10 hours ofinitial training within a continuous 12- month period;subsequent years up to 2 hours of follow-up trainingeach year after initial year)Medicare patients at risk forcomplications from diabetes,recently diagnosed with diabetes orpreviously diagnosed with diabetes(must certify DSMT need)Glaucoma Screening (annually for patients in one ofthe high risk groups)Patients with diabetes mellitus, familyhistory of glaucoma, AfricanAmericans age 50 and over, orHispanic-Americans age 65 and upProstate Cancer Screening (annually) –Digital rectal exam– Prostate specific antigen testScreening Pap Tests and PelvicExamination (annually if high-risk, or childbearingage with abnormal Pap test within past 3 years; every24 months for all other women)Screening Mammography (annually)Vaccines– Prevnar / Pneumococcal (at least 1 year apart)– Seasonal Influenza (once per flu season in the fall orwinter)– Hepatitis B (scheduled dosages required)All male patients 50 or olderAll female Medicare patientsAll female patients 40 or olderAll Medicare patients– May provide additionalpneumococcal vaccinations based onrisk and provided that at least 5 yearshave passed since previous dose– Hepatitis B, if medium/high riskProvider to give Personalized Health Plan to patient.DATE OF SERVICE:Previouslytested(If yes, when?)Scheduled forscreenings
All asymptomatic Medicare patients Colorectal Cancer Screening - Flexible sigmoidoscopy (4 years, or once every 10 years after a screening colonoscopy - Screening colonoscopy (every 24 months at high risk; every 10 years not at high risk) - Fecal occult blood test (annually) - Barium enema (every 24 months at high risk; every 4
