• Medicare Wellness

    Medicare Wellness

    Pre-Visit Questionnaire

  • This is your Medicare Health Risk Assessment or HRA that is an integral part of your Annual Wellness Visit (AWV), or your initial Welcome to Medicare Visit (called an IPPE).  This is to determine any risks or barriers to your health going forward.  These should be done every year, and there is no charge to you for these Medicare Appointments.  Please note that these appointments are primarily to determine your risks, and aren't for chronic care management, or acute illnesses.

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • GENERAL HEALTH

  • How is your overall health?*
  • How many different prescriptions are you taking?*
  • Do you take all of your medications as prescribed?*
  • How is the health of your teeth and mouth?*
  • Do you have a dentist that you visit regularly?*
  • How many times in the last six months were you admitted to the hospital?*

  • TOBACCO AND ALCOHOL USE

    HCPCS CODES 99406, G0442
  • Do you use any tobacco products?*
  • Are you interested in quitting tobacco?*
  • How many times in the past year have you had 4 or more alcoholic drinks in a day?*
  • Are you interested in receiving help for any other type of substance abuse?*

  • NUTRITION

  • How many servings of fruits and vegetables do you usually eat each day?*
  • How many servings of fiber or whole grain foods do you usually eat each day?*
  • How many servings of meat, fish, or other protein do you usually eat each day*
  • How many servings of fried or high=fat goods do you usually eat each day?*
  • How many servings of of sugar-sweetened drinks do you usually have each day*

  • PHYSICAL ACTIVITY

  • How many days a week to your exercise?*
  • On the days that you exercised, how long did you exercise?*
  • How intense is your exercise?*

  • SLEEP

  • How many hours of sleep do you usually getl?*
  • Do you snore or has anyone told you that you snore?*
  • In the past seven days, how often have you felt sleepy during the day?*

  • FUNCTIONAL STATUS ASSESSMENT

    CPT II CODE 1170F

  • Instrumental activities of daily living

  • Which of the following can you do on your own without help*

  • Activities of daily living

  • Which of the following can you do on your own without help?*
  • Many people experience leakage of urine, also called urinary incontinence. in the past six months, have you experienced leaking of urine?*

  • Ambulation status

  • How long can you walk or move around?*
  • Which of these assistive devices to you use?*
  • Do you have any trouble with your balance?*
  • Have you fallen in the past six months?*

  • Sensory ability

  • Do you have problems with vision?*
  • Do you use eyeglasses or contact lenses?*
  • Do you have problems hearing?*
  • Do you use hearing aids or other devices to help you hear?*

  • PAIN ASSESSMENT

    CPT II CODES 1125F, 1126F
  • In the past two weeks, how often have you felt pain?*

  • If you've had pain, where?

    Use the "Pen", the third icon from the left. Eraser is the fourth icon on the left. (Don't click the arrows or the "X", you may lose your work)
  • How to you treat the pain?*
  • Rate your worst pain in the past 2 weeks, on a scale of 0-10, with 0 being no pain, and 10 being the worst pain?*

  • HOME/SAFETY

  • What is your living situation?*
  • Does your home have working smoke alarms?*
  • Do you fasten your seatbelt in vehicles?*
  • If there are guns in your residence, are they locked with the ammunition secured separately?*

  • DEPRESSION - (PHQ-9)

    HCPCS CODE G0444
  • In the last two weeks, how often have you been bothered by any of the following problems?*
    Rows

  • SOCIAL/EMOTIONAL SUPPORT

  • Which of the following applies to you?*
  • How often do you get out and meet with family and/or friends?*

  • ADVANCE DIRECTIVES

    CPT II CODES 1157F, 1158F, HCPCS CODE S0257
  • Do you have a health care power of attorney or a living will*
  • Would you like more information on a power of attorney or a living will*

  • MEDICATIONS (PRESCRIPTIONS, VITAMINS, OVER THE COUNTER)

    CPT II CODE 1159F, 1160F
  • Medications
    Rows

  • SELF AND FAMILY MEDICAL HISTORY

  • Mark the columns that apply*
    Rows

  • OTHER HEALTH CARE PROVIDERS YOU'VE SEEN IN THE PAST 2 YEARS

  • Specialty
    Rows

  • ALLERGIES (DRUG, FOOD, ENVIRONMENT)

    IF NONE, ENTER "NONE" ON LINE #1
  • Rows

  • By clicking "Submit" below, this questionnaire will be securely routed to your provider for your upcoming Medicare Wellness Visit, and will be reviewed with you.

     
     
  • Birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • If you have an Advanced Directive, please bring it with you to your Wellness Appointment, we will add it to your medical record.

     
     
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