Community Memorial Health Systems (Adult Wellness Visit)

Adult Wellness Visit Visita bienestar adulto

Hospitalizations

Have you been hospitalized in the last year?

yes

no

Please list when and for what reason:

Osteoporosis Risk Assessment

Do you have any of these risk factors for osteoporosis? Select all that apply.

None

HIV Risk Assessment

Do you have any of these risk factors for HIV? Select all that apply.

Current or prior history being treated for a sexually transmitted disease (STD).

Current or prior history of intravenous drug use.

Male with male sexual relations after 1975.

Unprotected sexual intercourse with multiple partners.

Have exchanged sex for money or drugs or have had a partner who does.

Have had a sexual partner who is HIV positive, bisexual or is an intravenous drug user.

Have received medical care in a setting which has a high risk or high prevalence of HIV.

None

Drug and Alcohol Use

What is your smoking history?

Never smoked cigarettes

Former cigarette smoker

Quit date:

How many years did you smoke?

What was your daily use? (i.e. number of cigarettes per day)

5

10

15

20

30

40

50

60

Current cigarette smoker

What is your daily use? (i.e. number of cigarettes per day)

5

10

15

20

30

40

50

60

How many years have you been smoking?

What is your smokeless tobacco history?

Never used smokeless tobacco

Former smokeless tobacco user

Current smokeless tobacco user

What is your pipe/cigar smoking history?

Never used pipe/cigar

Former pipe/cigar user

Current pipe/cigar user

Are you interested in quitting?

yes

no

How would you describe your alcohol use?

Currently in recovery

Frequent use of alcohol

Binge drinking

Occasional use of alcohol

Never drinks alcohol

Are you interested in quitting?

yes

no

Diet and Physical Activity

How would you describe your current diet? Select all that apply.

Well-balanced

Low fat

Low salt

Unhealthy

Low carbohydrates

Limited junk food

Frequent junk food Frequentemente como comida no saludable

How frequently do you exercise?

Daily

Frequently

Infrequently

Never

Mood Screening

In the past two weeks, have you felt any of these symptoms of anxiety? Select all that apply.

Heart palpitations

Shortness of breath

Nervousness

Excessive worrying

Tremors

Sleep disturbances

None

In the past two weeks, have you felt down, depressed, or hopeless?

yes

no

In the past two weeks, have you felt little interest or pleasure in doing things?

yes

no

Cognition Screening

In the past several weeks, have you experienced difficulty in the following areas? Select all that apply.

Language use

Handling complex mental tasks

Memory

None

Functional Ability/Safety

How would you describe your ability to hear?

	Both ears Ambos oídos	Right ear Oído derecho	Left ear Oído izquierdo
Normal

Slight decrease Disminucion leve

Significant decrease Disminucion significativa

Do you use hearing aids?

yes

no

Due to health problems, do you feel you need the help of another person in any of the following activities of daily living? Select all that apply.

Eating

Incontinence

Bathing

Toileting

Dressing

Getting out of bed or chair

None

I do not need any help with the above activities

I need some help with the above activities

I require help with the above activities

Due to health problems, do you feel you need the help of another person in any of the following instrumental activities of daily living? Select all that apply.

Using the phone

Transportation

Shopping

Preparing meals

Doing housework

Doing laundry

Managing medications

Managing money

None

I do not need any help with the above activities

I need some help with the above activities

I require help with the above activities

In the past several weeks, has your physical and emotional health limited your social activities with family, friends, neighbors, or groups?

Not at all

Moderately

Extremely, I no longer participate in social activities

In the past several weeks, has your physical and emotional health limited your ability to drive?

Not at all

Moderately

Extremely, I no longer drive

Fall history:

No falls in past year

One fall without injury in past year

Two or more falls in past year

Any fall with injury in past year

Does your home have any of these safety risk factors? Select all that apply.

Uneven floors

Loose rugs

Poor lighting

No stair handrails

Household clutter

Unfamiliar surroundings

None

Advanced Directive

Have you completed any of the following Advanced Directives? Select all that apply.

Advanced Directives on File

DNR

None

Would you like the opportunity to discuss your end of life decisions or Advanced Directives with your provider?

yes

no

Additional Medical Providers & Medical Suppliers

Please list any additional medical providers that you currently see:

Audiologist

Name:

Cardiologist

Name:

Dentist

Name:

Dermatologist

Name:

Diabetes Educator

Name:

Endocrinologist

Name:

Gastroenterologist

Name:

Gynecologist

Name:

Hematologist/Oncologist

Name:

Internist

Name:

Nephrologist

Name:

Neurologist

Name:

Nutritionist

Name:

Ophthalmologist

Name:

Optometrist

Name:

Orthopedist

Name:

Otolaryngologist

Name:

Pain Management

Name:

Physical Therapist

Name:

Podiatrist

Name:

Primary Care Provider

Name:

Psychiatrist

Name:

Pulmonologist

Name:

Rheumatologist

Name:

Social Worker

Name:

Surgery

Name:

Urologist

Name:

Visiting Nurse

Name:

Other

Name:

Please list any Medical Suppliers you use:

Patient Information

Información del paciente

Adult Wellness Visit Visita bienestar adulto

Hospitalizations

Hospitalizaciones

Osteoporosis Risk Assessment

Evaluación de Riesgo de Osteoporosis

HIV Risk Assessment

Evaluación del riesgo de VIH

Drug and Alcohol Use

Uso de Drogas y Alcohol

Diet and Physical Activity

Dieta y actividad física

Mood Screening

Estado de Animo

Cognition Screening

Cognicion

Functional Ability/Safety

Capacidad funcional / seguridad

Advanced Directive

Directiva Anticipadas

Additional Medical Providers & Medical Suppliers

Proveedores de servicios médicos y productos medicales adicionales