Annual Wellness Visit Questionnaire – Lister Healthcare Group

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Welcome
About
Services
- Annual Wellness Visits
- Chronic Care Management
Practices
Announcements
Contact
Login
Register

Annual Wellness Visit Questionnaire

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Annual Wellness Questionnaire
Name*
First Last
Provider
Birthday*
Age*
Date of Last Exam*
Medicare B Eligibility Date

General Health
During 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 Being
During 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?*

Nutrition
How 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 Activity
Do 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 Drugs
Have 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 surgeries
Your 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 Visit
Past Surgeries (include date and description of any complications)
Reason for Visit
Facility
Attending Physician
Date of Visit
Past Surgeries (include date and description of any complications)
Reason for Visit
Facility
Attending Physician
Date of Visit
Past 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 below
Were 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

Health Risk Screens
Please check the box that applies to the questions below
Depression 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 Mental
What month is this?*
What year is this?*
What is your date of birth?*

Home Safety
Do 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 Activities
Can 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 Screen
Do 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 Screen
Do 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 Screen
Do 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 Screen
Do 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 Abnormalities
Do 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 Only
Have 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

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