Medicare Wellness Form

Medicare Wellness Questionnaire
Please complete this form for your patient care record

Please List All Physicians You Are Currently Seeing (you may leave some of these blank)
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Do you have an Advanced Directive? (Durable Power of Attorney for healthcare/ComfortOne/Living Will/POLST)

YESNO
If yes, may we have a copy for your file?

YESNO
Does your home have grab bars in the bathroom, handrails on the stairs?

YESNO
Does your home have rugs in the hallway?

YESNO
Do you need help with the phone, transportation, shopping, preparing meals, housework, laundry, medications or managing money?

YESNO
Does your home have poor lighting?

YESNO
Have you noticed hearing difficulties?

YESNO
Do you want a referral for a hearing evalutation?

YESNO
Over the last two weeks, have you been bothered by any of the following problems?
Little interest or pleasure in doing things?

YESNO
Feeling down, depressed, or hopeless?

YESNO
Date of last Colonoscopy (what year):
Date of last Mammogram (what year):
Date of last Flu shot (year):
Date of last Pneumonia shot (year):
Date of last Shingles or Chickenpox shot (year):
Date of last Tetanus shot (year):
Patient Name
Date of Birth:

MonthDayYear
Date
Patient Signature

Clear
Today's Date:

MonthDayYear
Date
Should be Empty:

Medicare Wellness Questionnaire