MEDICARE ANNUAL WELLNESS VISIT Please Complete this ChecklistDuring the past 2 weeks, how often have you been bothered by the following problems? Little interest or pleasure in doing things Not at all Several Days More then half the days Nearly Every Day Feeling down, depressed, or hopeless Not at all Several Days More then half the days Nearly Every Day Have you fallen two or more times in the past year? Yes No Are you afraid of falling? Yes No Are you limited in any way by your ability of hearing? Yes No During the past four weeks, how many drinks of wine, beer or any other alcoholic beverages did you have per week? 0 2-4 4-6 6-10 10+ Do you have trouble taking your medicines the way you have been told to take them? Yes No During the past 2 weeks has your physical and emotional health limited your social activities with family friends, neighbors or groups? Yes No During the past 2 weeks, how much bodily pain have you had? No pain Mild Pain Moderate Pain Severe Pain During the past 2 weeks, was someone available to help you if you needed or wanted help? Yes No Can you prepare your own meals? Yes No During the past 2 weeks, what was the hardest physical activity you could do for atleast two minutes? Heavy Light Moderate Can you get to places out of walking distance without help? Yes No Can you go shopping for groceries or clothes without someone's help? Yes No Can you do your house work without help? Yes No Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing or getting around the house? Yes No Can you handle your own money without any help? Yes No During the past 2 weeks, how would you rate your health in general? Excellent Fair Poor How have things been going for you during the past four weeks? Excellent Fair Poor Are you having difficulties driving your car? Yes No Do you always fasten your seat belt when you are in a car? Yes No Falling or dizzy when standing up Never Seldom Sometimes Often Always Sexual Problems Never Seldom Sometimes Often Always Teeth or Denture Never Seldom Sometimes Often Always Problems using the telephone Never Seldom Sometimes Often Always Trouble Eating Never Seldom Sometimes Often Always Tiredness or Fatigue Never Seldom Sometimes Often Always Are you a smoker? Yes No Are you limited in any way by your ability to see? Yes No Do you exercise for about twenty minutes three or more days a week? Yes No Have you been given any information to help you to keep track of your medicines? Yes No With hazards in the house that might hurt you? Yes No How confident are you that you can control and manage most of your health problems Very confident Somewhat confident Not very confident I do not have any health problems Do you or any of your friends or family members have concerns about you having any memory changes/loss? Yes No In the last 6 months, have you seen any other healthcare providers outside of your primary care physician? Yes No Do you have a living will/advanced directive (document that makes your health care wishes known)? Yes, and no updates Yes and I'd like to update No Health Risk Assessment What to Bring to Your Annual Wellness Visit Patient Name DOB Date Please list below the name of all providers and healthcare agencies involved in your healthcare.Name of ProviderSpecialityPlease list below the names of all the healthcare suppliers from who you receive medical equipment. This includes oxygen, durable medical equipment, etc. Name of SupplierEquipmentPlease list below the medications, supplements, vitamins you take, including over the counter drugs, vitamins, and herbal supplements. Medication/Supplements/VitaminsDoseFrequency (times per day)Pharmacy (include location)Activities of Daily Living For each skill area listed below, mark the statement (only one) that describes you most accurately. The word "assistance" means supervision or direction*Please bring all medications and over-the-counter medications with you to your office visitBathing I need help getting in or out of the tub or require total bathing I need help with bathing more than one part of the body I need help in bathing only a single part of body (such as back) I can bath myself completely independently Dressing I need help with getting dressed or need to be completely dressed I get clothes from the closet and can put them on without assistance (this does not include any help I require to tie my shoes) Toileting I need help getting on the toilet, cleaning myself, or use a bedpan I get on and off the toilet and clean genital area without help Transferring I need help moving from bed to chair that requires complete Assistance I move in and out of bed or chair without or with minimal assistance from a personal aide Continence I am partially incontinent or totally incontinent I exercise complete self-control over urination and defecation
