Annual Wellness Visit Questionnaire 1234567891011121314151617181920212223 Annual Wellness QuestionnaireName* First Last Provider Birthday*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Date of Last Exam*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Medicare B Eligibility DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 General HealthDuring the past 4 weeks, how would you rate your health in general?* Great Good Fair Okay Poor Terrible During the past 4 weeks are things getting better or worse for you?* Great Good Fair Okay Poor Terrible Are you having any trouble taking your medications as prescribed?* No Yes During the past 4 weeks, are you bothered by:Dizziness or falling when standing?* No Yes Sexual problems?* No Yes Trouble eating?* No Yes Teeth or denture problems?* No Yes Problems using the telephone?* No Yes Tiredness or fatigue?* No Yes Emotional Well BeingDuring the past 4 weeks have you been feeling down, depressed or hopeless?* No Yes During the past 4 weeks have you had little interest or pleasure in your usual activities?* No Yes When you feel unwell or distressed who do you go to for help?* NutritionHow many days a week do you eat a good breakfast?* 0 1-3 4+ How many sweetened drinks do you have a day (Coke, Diet Coke, Pepsi, etc)?* 0 1-3 4+ How many servings of fruit or vegetables do you have a day?* 0 1-3 4+ How many times per week do you eat with your family?* 0 1-3 4+ Physical ActivityDo you exercise for about 20 minutes 3 or more days a week?* No Yes How intense is your workout? Heavy Moderate Light Alcohol, Caffeine, Tobacco and DrugsHave you used tobacco (cigarette, cigar or chew) over 100 times in your lifetime?* No Yes Have you used tobacco at all in the last 4 weeks?* No Yes How many times a day do you drink caffeinated beverages (coffee, tea, energy drinks)?* 0 1-2 3+ Do you believe you have a problem with alcohol?* No Yes How many alcoholic beverages do you consume in a day?* 0 1-3 4+ Have you ever abused drugs, prescriptions or otherwise?* No Yes Medical History Please check if you have had any of the following conditions or surgeriesYour Medical Conditions Alcoholism Anemia Asthma Arthritis Bladder Problems Blindness Blood Disorder Blood Clots Breast Cancer Colon Cancer Colon Polyps Cancer - Other Cataracts Depression Diabetes Emphysema (COPD) Gastric Reflux (GERD) Glaucoma Gout Hay Fever Hearing Loss Heart Attack Heart Disease Hepatitis High Cholesterol HIV/AIDS Hypertension (High BP) Jaundice Kidney Disease Kidney Stones Liver Disease Mental Illness Neurological Disease Osteoporosis Pacemaker Physical Disability Pneumonia Rheumatic Fever Seizure Disorder Sleep Disorder Stomach Disorder Stroke (CVA) Thyroid Disease Tuberculosis (TB) Ulcer Your Surgeries Abdominal Appendectomy Back Surgery Breast Surgery C-Section Colonoscopy D&C EGD (stomach scope) Eye Surgery Gallbladder Heart Cath Heart Surgery Hernia Repair Hip Surgery Hysterectomy Knee Surgery Nasal Surgery Neck Surgery Sinus Surgery Ovarian Surgery Plastic Surgery Thyroidectomy Tonsil/Adenoid Tubal Ligation Vasectomy Prostate Surgery Comments/Other Chronic Problems & Surgeries Hospital/Urgent Care Visits in the Past Year No visits in the past year Reason for Visit Facility Attending Physician Date of VisitMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Past Surgeries (include date and description of any complications) Reason for Visit Facility Attending Physician Date of VisitMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Past Surgeries (include date and description of any complications) Reason for Visit Facility Attending Physician Date of VisitMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Past Surgeries (include date and description of any complications) Family Medical History Please select if a blood relative has had any problem(s) from those listed belowWere you adopted?* No Yes Alcohol Abuse Father Mother Brother Sister Grandparent Other Substance Abuse Father Mother Brother Sister Grandparent Alzheimer's Father Mother Brother Sister Grandparent Dementia Father Mother Brother Sister Grandparent Breast Cancer Father Mother Brother Sister Grandparent Colon Cancer Father Mother Brother Sister Grandparent Prostate Cancer Father Mother Brother Sister Grandparent Cancer - Other Father Mother Brother Sister Grandparent Diabetes Father Mother Brother Sister Grandparent Emotional or Mental Illness Father Mother Brother Sister Grandparent Suicide Father Mother Brother Sister Grandparent Hypertension Father Mother Brother Sister Grandparent Heart Attack Father Mother Brother Sister Grandparent Osteoporosis Father Mother Brother Sister Grandparent Seizures Father Mother Brother Sister Grandparent Stroke Father Mother Brother Sister Grandparent Tuberculosis Father Mother Brother Sister Grandparent Specialists, Other Caregivers and Medical Device Assistant Eye doctor, cardiologists, home health services, cane, wheelchair, walkers, oxygen, etc.)Specialist Name(s) and Phone Number(s)Service Company Name(s) and Phone Number(s)Caregiver Name(s) and Phone Number(s)Comments Allergies No Known Allergies Penicillin Reaction Sulfa Drugs Reaction Codeine Reaction Aspirin Reaction Other Reaction Other Reaction Medications All prescription medications, herbal supplements, vitamins, over-the-counter medications, etc. None Medication Name Dosage Frequency Medication Name Dosage Frequency Medication Name Dosage Frequency Medication Name Dosage Frequency Medication Name Dosage Frequency Medication Name Dosage Frequency Medication Name Dosage Frequency Medication Name Dosage Frequency Medication Name Dosage Frequency Medication Name Dosage Frequency Health Risk Screens Please check the box that applies to the questions belowDepression Screening Over the last 2 weeks, how often have you been bothered by any of the following problems?1. Little interest or pleasure in doing things?* Not at all Several days More than 7 days Nearly everyday 2. Feeling down, depressed or hopeless?* Not at all Several days More than 7 days Nearly everyday 3. Trouble falling or staying asleep or sleeping too much?* Not at all Several days More than 7 days Nearly everyday 4. Feeling tired or having little energy?* Not at all Several days More than 7 days Nearly everyday 5. Poor appetite or overeating?* Not at all Several days More than 7 days Nearly everyday 6. Feeling bad about yourself, or that you’re a failure or have let yourself or your family down?* Not at all Several days More than 7 days Nearly everyday 7. Trouble concentrating on things, such as reading the newspaper or watching television?* Not at all Several days More than 7 days Nearly everyday 8. Moving or speaking so slowly that other people have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual.* Not at all Several days More than 7 days Nearly everyday 9. Thoughts that you would be better off dead or that you wanted to hurt yourself in some way.* Not at all Several days More than 7 days Nearly everyday If you check off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?* Not difficult at all Somewhat difficult Very difficult Extremely Difficult Mini MentalWhat month is this?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberWhat year is this?* What is your date of birth?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Home SafetyDo you have throw rugs on hardwood floors in your house?* No Yes Do you have pets that stay indoors?* No Yes Does your house have smoke alarms and carbon monoxide detectors in good working order?* No Yes Does your bathtub contain a safety measure such as a rubber mat or strips?* No Yes Is the area in front of your bathtub carpeted or protected by a bathmat with rubber backing?* No Yes Do you have night lights in your house?* No Yes Do you have loose or frayed cords or overloaded electrical sockets in your house?* No Yes Do you unplug household appliances when not in use?* No Yes Do you keep medicines in a safe place and have their directions clearly labeled?* No Yes Do you keep knives and other sharp objects put away in a safe place?* No Yes Do you keep poisons, chemicals or other toxic substances put away in a safe place?* No Yes Do you have furniture (tables) with sharp corners or a rickety chair that could cause injury?* No Yes Are there loose carpets, poor lighting, lack of handrails or grab bars in your home?* No Yes Do you always fasten your seatbelt when you are in the car?* No Yes Functional ActivitiesCan you get out of bed by yourself?* No Yes Can you dress yourself without help?* No Yes Can you prepare your own meals?* No Yes Do you do your own shopping?* No Yes Do you write checks and pay your own bills?* No Yes Do you drive or have other means of transportation for traveling outside your neighborhood?* No Yes Are you able to keep track of appointments and family occasions?* No Yes Are you able to take medicine according to directions, dosing, etc?* No Yes Are you able to keep track of current events?* No Yes Are you still able to play games of skill that you enjoy or work on a favorite hobby?* No Yes During the past 4 weeks, how would you rate your bodily pain?* Great Good Fair Poor Bad Terrible Can you go to places that are within walking distance without help?* No Yes Can you prepare your own meals, housework or shopping without help?* No Yes Do you need help eating, bathing or getting around the house?* No Yes Do you have memory problems that make it difficult for you to do your daily activities?* No Yes Fall Risk ScreenDo you notice numbness in your feet?* No Yes Do your steps feel “heavy” when you walk?* No Yes Do you ever feel light-headed upon rising from a seated position?* No Yes When walking, can you start and stop without difficulty?* No Yes Do you have trouble getting out of a chair?* No Yes Do you have any kind of difficulty when walking?* No Yes Do you ever lose your balance with movements such as bending over, turning around, etc?* No Yes Have your ever fallen two or more times in the past year?* No Yes Are you afraid of falling?* No Yes Hearing Loss ScreenDo you wear hearing aids?* No Yes Do you have a problem hearing over the telephone?* No Yes Do you have trouble following the conversation when two or more people talk at the same time?* No Yes Do people complain that you turn the TV or radio volume up to high?* No Yes Do you have to strain to understand conversation?* No Yes Do you have trouble hearing in a noisy background (party, movie theater)?* No Yes Do you find yourself asking people to repeat themselves?* No Yes Do many people you talk to seem to mumble, or not speak clearly?* No Yes Do you misunderstand what others are saying and respond inappropriately?* No Yes Do you have trouble understanding the speech of women and children?* No Yes Do people get annoyed because you misunderstood what they say?* No Yes Urinary Incontinence ScreenDo you leak urine, even is small drops:when you cough or sneeze?* No Yes when you bend down or lift something?* No Yes when you walk quickly, jog or exercise?* No Yes while you are undressing to use the toilet?* No Yes do you get a strong urge to urinate that you leak urine before you reach the toilet?* No Yes do you have to rush to the bathroom because you get a sudden strong need to urinate?* No Yes Has leakage affected your ability to:do household chores?* No Yes participate in walking, exercise, etc?* No Yes participate in movies, concerts etc?* No Yes travel by car more than 30 minutes from home?* No Yes participate in social activities?* No Yes does leakage have you feeling frustrated, nervous or depressed?* No Yes Osteoporosis Risk ScreenDo you have documented Osteoporosis or Osteopenia?* No Yes Are you older than 65 years of age?* No Yes Have you ever had a Bone Densitometry?* No Yes Do you take or have you ever been on cortisone, prednisone or other steroids for greater than 3 months during your life?* No Yes Are you thin, small boned or weigh less than 127 lbs?* No Yes Do you drink alcoholic beverages and smoke?* No Yes Does anyone in your immediate family have Osteoporosis?* No Yes Do you live an inactive lifestyle (does not exercise)?* No Yes Medication (Current or Past) Blood Thinner (Coumadin, Warfarin) Cancer (radiation, chemo) Rheumatism (Methotrexate) Seizure (Dilantin, Depakote) Water Pill (Furosemide) Thyroid (Synthroid, Levothyroid) Osteoporosis (Fosamax, Prolia) Other Disorder (Current or Past) Alcoholism Kidney Stones Cancer Malabsorption Eating Disorder Rheumatism Hyperparathyroidism Thyroid Disease Other Bone/Vertebral AbnormalitiesDo you have a backache, humped back (kyphosis) or back curvature (scoliosis)?* No Yes Do you have abnormal posture?* No Yes Have you lost over 1 inch in height since age 25?* No Yes Have you had a compression fracture of the back?* No Yes Have you had Hip Replacement Surgery?* No Yes Have you broken any bones without much effort or trauma?* No Yes Women OnlyHave you stopped having periods (post menopausal)? No Yes If yes, please answer the following: Did your periods stop before age 45? No Yes Did you have your ovaries removed? No Yes Are you experiencing hot flashes, sleeplessness, headaches, lack of concentration, vaginal dryness or decreased libido? No Yes Men Only (Prostate Disorder Risk)Over the past month how often have you had a sensation of not emptying your bladder completely after you finished urinating? Not at all Less than 1-5 times Less than half the time About half the time More than half the time Almost always Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Not at all Less than 1-5 times Less than half the time About half the time More than half the time Almost always Over the past month, how often have you stopped and started again several times when you urinated? Not at all Less than 1-5 times Less than half the time About half the time More than half the time Almost always Over the past month, how often have you found it difficult to postpone urination? Not at all Less than 1-5 times Less than half the time About half the time More than half the time Almost always Over the past month, how often have you had a weak urinary stream? Not at all Less than 1-5 times Less than half the time About half the time More than half the time Almost always Over the past month, how often have you had to push or strain to begin urination? Not at all Less than 1-5 times Less than half the time About half the time More than half the time Almost always Over the past month, typically, how many times did you get up to urinate during the night? None 1 time 2 times 3 times 4 times 5 or more times
