Medicare Wellness Exam

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General Information

Name *

Date of Birth *

Month

Day

Year

How old are you? *

Are you male or female? *

What is your race? (Check all that apply) *

Recent History

During the past four weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad or downhearted and blue? *

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

During the past four weeks, how much bodily pains have you generally had? *

During the past four weeks, was someone available to help you if you needed and wanted help? *

(For example, if you felt very nervous, lonely, or blue; got sick and had to stay in bed; needed someone to talk to; needed help with daily chores; or needed help just taking care of you.)

During the past four weeks, what was the hardest physical activity you could do for at least 2 minutes? *

During the past four weeks, how would you rate your health in general? *

During the past four weeks how have things been going for you? *

During the past four weeks have been bothered by: Falling or dizzy when standing up *

During the past four weeks have been bothered by: Problems using the telephone *

During the past four weeks have been bothered by: Sexual problems. *

During the past four weeks have been bothered by: Teeth or denture issues *

During the past four weeks have been bothered by: Tiredness or fatigue *

During the past four weeks have been bothered by: Trouble eating well *

During the past four weeks, how many drinks of wine, beer, or other alcoholic beverages did you have? *

Tobacco Usage

Have you ever used tobacco? *

Have you ever used cigarettes?

Cigarettes: How many years?

Cigarettes: Age Started?

Cigarettes: Age Stopped

Cigarettes: How many per day?

Have you ever used cigarillos?

Cigarillos: How many years?

Cigarillos: Age Started?

Cigarillos: Age Stopped

Cigarillos: How many per day?

Have you ever used Cigars?

Cigars: How many years?

Cigars: Age Started?

Cigars: Age Stopped

Cigars: How many per day?

Have you ever used a pipe?

Pipe: How many years?

Pipe: Age Started?

Pipe: Age Stopped

Pipe: How many per day?

Have you ever used chewing tobacco?

Chewing: How many years?

Chewing: Age Started?

Chewing: Age Stopped

Chewing: How many per day?

Have you ever used smokeless tobacco?

Smokeless: How many years?

Smokeless: Age Started?

Smokeless: Age Stopped

Smokeless: How many per day?

Have you ever used smokeless snuff?

Snuff: How many years?

Snuff: Age Started?

Snuff: Age Stopped

Snuff: How many per day?

Personal Conditions

Because of any health problems, do you need anyone’s help with your basic needs such as eating, bathing, dressing or getting around the house? *

Can you do your housework without help? *

Can you get to places out of walking distance without help? (For example, can you travel alone on buses or taxis, or drive your own car?) *

Can you handle your own money without help? *

Are you having difficulties driving your car? *

Do you exercise for about 20 minutes three or more days a week? *

Have you been given any information to help you with the following: Hazards in your house that might hurt you? *

Have you been given any information to help you with the following: Keeping track of your medications? *

How confident are you that you can control and manage most of your health problems? *

Do you have adequate vision to complete daily activities?

Is your judgement adequate to complete daily activities?

Is your memory safe to complete daily activities?

Are you able to express your needs and/or desires adequately?

How independent is your grooming ability?

How independent are you when it comes to feeding yourself?

How independent is your bathing ability?

Are you able to use the bathroom independently?

How independent are you getting in and out of bed?

How independent are you when walking in your home?

Environmental Conditions

Do you have carbon monoxide detectors in your home? *

Do you have firearms in your home? *

Do you have radon in your home? *

Is the radon treated or untreated?

Do you have smoke detectors in your home? *

Do you use seatbelts when in a vehicle? *

What type of ambulatory device do you use: *

Physical Conditions

Which is your dominant hand? *

How many falls have you had in the past year? *

If you answered yes to the previous question did your falls result in injury? Please describe

Do you have weakness in your arms/hand? If so, which arm/hand?

Do you have weakness in your legs? If so, which leg?

How is the hearing in your right ear?

How is the hearing in your left ear?

How often do you

How often do you have trouble taking medicines the way you have been told to do? *

How often do you: Feel little interest or pleasure in activities *

How often do you: Down, depressed or hopeless? *

How often do you: Have trouble falling or staying asleep? *

How often do you: Sleep too much? *

How often do you: Have a poor appetite or overeat? *

How often do you: Feel that you are a failure or have let yourself and others down? *

How often do you feel tired or have little energy? *

How often do you: Have trouble concentrating on activities? *

How often do you: Move or speak very slowly to a point that it is noticeable to others? *

How often do you: Feel that you would be better off dead or hurt yourself? *

If you checked off any of the above 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?

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Medicare Wellness Exam

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Medicare Wellness Exam