AWV Questionaire

Blue Sky MD Health Office Location
Name :
DOB :

MonthDayYear
Depression Screening (PHQ2):

	NOT AT ALL	SEVERAL DAYS	MORE THANONEHALF THE DAYS	NEARLY EVERY DAY
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

Wellness Profile:
Number of Falls in the last 12 months:
Do you have any of the following existing conditions: Anxiety   Alzheimer’s   Dementia   Depression   None
Emergency room visits in the last 6 months:
Hospital stays in the last 6 months:
New vision problems: Yes   No
Decreased hearing: Yes   No
Do you or your family have concerns about your memory: Yes   No
Overall Health: Excellent   Good   Fair   Poor
Please check all of the activities of daily living that require assistance of any kind (human or mechanical):

Ambulation/Transferring from sitting to standingBathing/ShoweringContinenceDressingFeedingFinancesFood PreparationHousekeepingLaundryMedication ManagementShoppingToileting:Transportation
Other contributing Difficulties: None Live in an unsafe environment Lacking transportation Financial difficulty
Difficulty reading or understanding instructions Lonely Frequent falls
Vaccines:
Flu Shot (one every 12 months)  Date:    Pneumonia Shot (Part B covers the first shot at any time and a different, second shot if it’s given at least one year after the first shot)Date: Date
Hepatitis B Shot Date:
Hemophilia   Have ESRD
Diabetic   Live with someone who ha
Males ONLY(over the age of 50):
Prostate Screening (Digital Rectal Exam)
Date:
Prostate Screening (bloodwork) Date:

Females ONLY
Pap Smear Date: Date
Mammogram Date:
Immunizations:
TDAP Date: Date
Shringrix Date: Date
Pnew 23 Date:
Prevnar 13 Date: Date
TDAP Date: Date
Last Colonoscopy: Date
Results: Normal Abnormal
Bone Scan (DEXA): Date
Results:Normal Abnormal
Surgical & Hospitalization History (please list surgeries and month and year of surgery/hospitalization):

	PROVIDER/GROUP/CLINIC NAME	CITY & STATE
Primary Care Provider:
Cardiologist:
Pain Specialist:
Pharmacy:
Pulmonary Specialist:
Dentist:
Other

Depression Screening (PHQ2):

Wellness Profile:

Family History

Do any of the following apply to your immediate `blood’ relatives? Please circle

Social History: