ANNUAL WELLNESS VISIT
WESTERN WAKE WELLNESS, PLLC
Name I would like to be called:
Pharmacy Name & Location
Please list all allergies to Medication or Food
To help us coordinate your care, please list any medical providers you see outside this practice:
How often do you exercise?
If at all, what do you to do exercise?
When did you quit smoking?
In the last 7 days, how many days did you drink alcohol?
Recreational Drug Use:
If at all, how do you get caffeine?
Diet pills or supplements
How much caffeine do you drink per day?
How many people live in your household?
Who lives with you?
Are there any changes in your living situation? If so, please explain:
In general, would you say your health is:
How have things been going for you during the past 4 weeks?
Very well; could hardly be better
Good and bad parts about equal
Very bad; could hardly be worse
During the last 4 weeks, how much bodily pains have you generally had?
Very mild pain
During the past 4 weeks, how much have you been bothered by feelings of anxiety, depression, irritability, or sadness?
Not at all
Quite a bit
During the past 4 weeks, has your physical or emotional health limited your social activities with friends?
Not at all
Quite a bit
How often in the last 4 weeks have you been bothered by any of the following problems:
Falling or dizzy when standing up
Sexual problems or concerns
Trouble eating well
Teeth or denture problems
Problems using the phone
Tiredness or fatigue
Do you have difficulty getting out of chair without assistance?
Have you fallen two or more times in the past year?
Are you afraid of falling? Do you feel unsteady?
Do you use a cane or walker?
HEARING LOSS SCREENING
How often in the last 4 weeks have you experienced the following:
Straining to understand a conversation
Trouble hearing in a noisy background
Misunderstanding what others are saying
Do you notice any new or worsening problems with your vision?
How confident are you that you can control and manage most of your health problems/issues?
Not very condifent
I do not have any health problems
How often do you have trouble taking medications the way you have been told to take them?
I do not have to take medicine
I always take them as directed
Sometimes I have trouble taking them as directed
I seldom take them as directed or often have trouble taking them as directed
Do you have someone who is available to help you if you needed or wanted help?
Yes, as much as I want/need
If you need help with shopping, transportation, preparing meals or taking your medications correctly please describe:
Because of any health problems, if you need the help of another person with your personal care needs, such as eating, bathing, dressing or getting around the house, please describe:
Can you handle your own money without help?
Are you having difficulties driving your car?
N/A, I do not use a car
Do you always fasten your seat belt when you are in a car?
Type a question
Does your home have smoke or carbon monoxide alarms?
Is your home well lit, especially when you get up at night?
Are your sidewalks/entryways well maintained?
Do you have rails on stairs?
Do you have to grab bars in the bathroom?
Do you have throw rugs, electrical cords, or other obstacles in your walking space?
Are all medicines kept in original containers with original labels intact?
Do you throw out all unidentified or out-of-date medications?
Do you have a Healthcare POA or Living Will?
Would you like to discuss Advance Directives?
Are there any religious or cultural factors that you would like us to take into account when planning your healthcare?
Type option 3
Type option 4
If yes, please describe:
Should be Empty: