ANNUAL WELLNESS VISIT
WESTERN WAKE WELLNESS, PLLC
Patient Name:
First Name
Last Name
Birth Date:
-
Month
-
Day
Year
Age:
Today's Date:
-
Month
-
Day
Year
Name I would like to be called:
Pharmacy Name & Location
Please list all allergies to Medication or Food
SURGERIES
HOSPITAL ADMISSIONS
SPECALTY PROVIDERS
To help us coordinate your care, please list any medical providers you see outside this practice:
Cardiology
Pulmonology
OB/Gynecology
Urology
Dermatology
Nephrology
Gastroenterology
Neurology
Pain Specialist
ENT/Otolaryngology
Allergy/Immunology
Orthopedics
Rheumatology
Hematology/Oncology
Infectious Disease
Podiatrist
Ophthalmology/Optometry
Psychiatrist/Psychologist
Surgeon
Configurable list
SOCIAL HISTORY
How often do you exercise?
None
1-2x Weekly
3-5x Weekly
Every Day
If at all, what do you to do exercise?
Tobacco Use:
Never
Former Smoker
Current
When did you quit smoking?
Alcohol Use:
Yes
No
In the last 7 days, how many days did you drink alcohol?
Recreational Drug Use:
No
Past
Current
Caffeine Use:
No
Yes
If at all, how do you get caffeine?
Coffee
Soda
Tea
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:
FUNCTIONAL STATUS
In general, would you say your health is:
Excellent
Very Good
Fair
Poor
How have things been going for you during the past 4 weeks?
Very well; could hardly be better
Pretty well
Good and bad parts about equal
Pretty bad
Very bad; could hardly be worse
During the last 4 weeks, how much bodily pains have you generally had?
No pain
Very mild pain
Mild pain
Moderate pain
Severe pain
During the past 4 weeks, how much have you been bothered by feelings of anxiety, depression, irritability, or sadness?
Not at all
Slightly
Moderately
Quite a bit
Extremely
During the past 4 weeks, has your physical or emotional health limited your social activities with friends?
Not at all
Slightly
Moderately
Quite a bit
Extremely
How often in the last 4 weeks have you been bothered by any of the following problems:
Rows
Never
Seldom
Sometimes
Often
Always
Falling or dizzy when standing up
Sexual problems or concerns
Trouble eating well
Teeth or denture problems
Problems using the phone
Tiredness or fatigue
Problems sleeping
Walking Questions
Rows
Yes
No
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:
Rows
Never
Seldom
Sometimes
Often
Always
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?
No
Yes
How confident are you that you can control and manage most of your health problems/issues?
Very confident
Somewhat confident
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, some
Yes, as much as I want/need
No
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?
No
Yes
Are you having difficulties driving your car?
No
Yes, often
Sometimes
N/A, I do not use a car
Do you always fasten your seat belt when you are in a car?
Yes, always/usually
Yes, sometimes
No
HOME SAFETY
Type a question
Rows
Yes
No
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?
ADVANCED DIRECTIVES
Do you have a Healthcare POA or Living Will?
No
Yes
Would you like to discuss Advance Directives?
No
Yes
Are there any religious or cultural factors that you would like us to take into account when planning your healthcare?
No
Yes
Type option 3
Type option 4
If yes, please describe:
Submit
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