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)
If yes, may we have a copy for your file?
Does your home have grab bars in the bathroom, handrails on the stairs?
Does your home have rugs in the hallway?
Do you need help with the phone, transportation, shopping, preparing meals, housework, laundry, medications or managing money?
Does your home have poor lighting?
Have you noticed hearing difficulties?
Do you want a referral for a hearing evalutation?
Over the last two weeks, have you been bothered by any of the following problems?
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
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
2 digit month, 2 digit day, 4 digit yearDate
Patient Signature
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Medicare Wellness Questionnaire