Medicare Annual Wellness Visit Health Risk Assessment
PERSONAL INFORMATION
How do you prefer we communicate? Phone/Text Area Code Phone Number Email: Email
GENERAL HEALTH
MEDICATIONS - Prescriptions, Vitamins, Over-the-Counter
If you are on any new medications since your last visit please list them below. Name Dose Date Started Condition Treating Name Dose Date Started Condition TreatingName Dose Date Started Condition Treating Name Dose Date Started Condition Treating Name Dose Date Started Condition Treating Name Dose Date Started Condition Treating Name Dose Date Started Condition Treating Name Dose Date Started Condition Treating Name Dose Date Starting Condition Treating
TOBACCO AND ALCOHOL USE
FUNCTIONAL STATUS ASSESSMENT
Activities of daily living (ADL's) - Please select all those that apply.Which of the following can you do on your own without help? Bathe Dress Eat Walk Use the restroom Transfer in/out of chairs, etc None
Does someone help you at home? Yes No Spouse Children Other: If yes, please provide Caregiver Name:First Name Last Name Aide/Caregiver #:Area Code Phone Number
Instrumental activities of daily living (IADL’s) - Please select those that apply.Which of the following can you do on your own without help?Shop for groceries Use the telephone Housework Handle finances Drive/Use public transportation Take Medications Make meals None
RISK FOR FALLING
Which of these assistive devices do you use? Please select all that applyCane Walker Wheelchair Crutches Other None
ADVANCE DIRECTIVES
Does your family or friends know what you want in an emergency situation or if you could not speak for yourself?Please select all that applyIf you have any of the following, it would be helpful to have a copy provided to us for your medical record. Yes, I have a living will Yes, I have a power of attorney Yes, I have a POLST Yes, I have completed 5 wishes No
DEPRESSION PHQ-9