Please Complete this Checklist

During the past 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Have you fallen two or more times in the past year?
Are you afraid of falling?
Are you limited in any way by your ability of hearing?
During the past four weeks, how many drinks of wine, beer or any other alcoholic beverages did you have per week?
Do you have trouble taking your medicines the way you have been told to take them?
During the past 2 weeks has your physical and emotional health limited your social activities with family friends, neighbors or groups?
During the past 2 weeks, how much bodily pain have you had?
During the past 2 weeks, was someone available to help you if you needed or wanted help?
Can you prepare your own meals?
During the past 2 weeks, what was the hardest physical activity you could do for atleast two minutes?
Can you get to places out of walking distance without help?
Can you go shopping for groceries or clothes without someone's help?
Can you do your house work without help?
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?
Can you handle your own money without any help?
During the past 2 weeks, how would you rate your health in general?
How have things been going for you during the past four weeks?
Are you having difficulties driving your car?
Do you always fasten your seat belt when you are in a car?
Falling or dizzy when standing up
Sexual Problems
Teeth or Denture
Problems using the telephone
Trouble Eating
Tiredness or Fatigue
Are you a smoker?
Are you limited in any way by your ability to see?
Do you exercise for about twenty minutes three or more days a week?
Have you been given any information to help you to keep track of your medicines?
With hazards in the house that might hurt you?
How confident are you that you can control and manage most of your health problems
Do you or any of your friends or family members have concerns about you having any memory changes/loss?
In the last 6 months, have you seen any other healthcare providers outside of your primary care physician?
Do you have a living will/advanced directive (document that makes your health care wishes known)?

Health Risk Assessment What to Bring to Your Annual Wellness Visit

Please list below the name of all providers and healthcare agencies involved in your healthcare.

Please list below the names of all the healthcare suppliers from who you receive medical equipment. This includes oxygen, durable medical equipment, etc.

Please list below the medications, supplements, vitamins you take, including over the counter drugs, vitamins, and herbal supplements.

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 visit