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Medicare Wellness Visit
After you select the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
My provider is not in the list
---------- Date of Birth ----------
First Name
Last Name
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Year
Gender
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Male
Female
Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
If not listed here: Please Discuss with your Physician
Reason for Visit
Welcome to Medicare Visit
Initial Annual Wellness Visit
Subsequent Annual Wellness Visit
If not listed here: Please Discuss with your Physician
Hospitalizations
Have you been hospitalized in the last year?
yes
no
If yes, please list when and for what reason:
If not listed here: Please Discuss with your Physician
Osteoporosis Risk Assessment
Do you have any of these risk factors for osteoporosis? Mark all that apply.
Female
Low body weight (<127 lbs)
History of tobacco use/current tobacco use
Asian
Age 50 or above
History of alcohol use/current alcohol use
Caucasian
Low calcium diet
Personal history of fracture or broken bones
None
Family history of fracture or broken bones
If not listed here: Please Discuss with your Physician
HIV Risk Assessment
Do you have any of these risk factors for HIV? Mark all that apply.
None
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.
If not listed here: Please Discuss with your Physician
Drug and Alcohol Use
What is your smoking history?
Never smoked cigarettes
Former cigarette smoker
Quit date:
How many years did you smoke?
.5
1
3
5
7
10
15
20
25
30
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?
.5
1
3
5
7
10
15
20
25
30
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
If you currently use tobacco products, are you interested in quitting?
yes
no
How would you describe your alcohol use?
Frequent use of alcohol
Binge drinking
Occasional use of alcohol
Currently in recovery
Never drink alcohol
Your typical consumption of alcohol:
1
2
3
4
5
6
7
8
9
10
drinks per:
Day
Week
Month
Are you interested in quitting?
yes
no
If not listed here: Please Discuss with your Physician
Diet and Physical Activity
How would you describe your current diet? Mark all that apply.
Low fat
Low salt
Low carbohydrates
Well-balanced
Unhealthy
Limited junk food
Frequent junk food
How frequently do you exercise?
Daily
Frequently
Infrequently
Never
Minutes per day:
5
10
15
20
25
30
45
60
90
120
200
Times per week:
1
2
3
4
5
6
7
Hours per week:
1
2
3
4
5
6
7
8
9
10
If not listed here: Please Discuss with your Physician
Mood Screening
In the past two weeks, have you felt any of these symptoms of anxiety? Mark all that apply.
Shortness of breath
Nervousness
Heart palpitations
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
If not listed here: Please Discuss with your Physician
Cognition Screening
In the past several weeks, have you experienced difficulty in the following areas? Mark all that apply.
Language use
Handling complex mental tasks
Memory
None
If not listed here: Please Discuss with your Physician
Functional Ability/Safety
How would you describe your ability to hear?
Both ears
Right ear
Left ear
Normal
Slight decrease
Significant decrease
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? Mark all that apply.
Incontinence
Bathing
Eating
Getting out of bed or chair
Dressing
Toileting
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? Mark 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
Have you experienced any of these risk factors for falling? Mark all that apply.
Previous falls in the past years
Alcohol use
General weakness
Difficulties in moving
Sedative use
Urinary incontinence
Visual impairment
Antihypertensive use
None
Does your home have any of these safety risk factors? Mark all that apply.
Loose rugs
Poor lighting
Uneven floors
No stair handrails
Household clutter
Unfamiliar surroundings
None
If not listed here: Please Discuss with your Physician
Advanced Directive
Have you completed any of the following Advanced Directives? Mark all that apply.
Living will
Durable power of attorney
POLST
None
Would you like the opportunity to discuss your end of life decisions or Advanced Directives with your provider?
yes
no
If not listed here: Please Discuss with your Physician
Additional Medical Providers & Medical Suppliers
Please list any additional medical providers that you currently see:
Audiologist
Nephrologist
Podiatrist
Cardiologist
Neurologist
Primary Care Provider
Dentist
Nutritionist
Psychiatrist
Dermatologist
Opthalmologist
Pulmonologist
Diabetes Educator
Optometrist
Rheumatologist
Endocrinologist
Orthopedist
Social Worker
Gastroenterologist
Otolaryngologist
Surgery
Gynecologist
Pain Management
Urologist
Hematologist/Oncologist
Physical Therapist
Visiting Nurse
Internist
Other:
Please list any Medical Suppliers you use:
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