A Checklist For Your Medicare Annual Wellness Visit
Please complete this checklist before seeing your doctor or nurse. Your answers will help you receive the best healthcare possible.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Today's Date
-
Month
-
Day
Year
Date
1. During the past 4 weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad or downhearted and blue?
Not at all
Slightly
Moderately
Quite a bit
Extremely
2. During the past 4 weeks, has your physical and emotional health limited your social activities with family friends, neighbors or groups?
Not at all
Slightly
Moderately
Quite a bit
Extremely
3. During the past 4 weeks, how much bodily pain have you generally had?
No pain
Very mild pain
Mild pain
Moderate pain
Severe pain
4. During the past 4 weeks, was someone available to help you if you needed and wanted help? For example, if you felt very nervous, lonely or blue, got sick and had to stay in bed, needed someone to talk to, needed help with daily chores, or needed help just taking care of yourself.
Yes, as much as I wanted
Yes, quite a bit
Yes, some
Yes, a little
No, not at all
5. During the past 4 weeks, what was the hardest physical activity you could do for at least 2 minutes?
Very heavy
Heavy
Moderate
Light
Very light
6. Can you get places out of walking distance without help? For example, can you travel alone by bus, taxi, or drive your own car?
Yes
No
7. Can you shop for groceries or clothes without help?
Yes
No
8. Can you prepare your own meals?
Yes
No
9. Can you do your own housework without help?
Yes
No
10. Can you handle your own money without help?
Yes
No
11. Do you need help eating, bathing, dressing, or getting around your home?
Yes
No
12. During the past 4 weeks, how would you rate your health in general?
Excellent
Very good
Good
Fair
Poor
13. How have things been going for you during the past 4 weeks?
Very well - could hardly be better
Pretty good
Good and bad parts about equal
Pretty bad
Very bad - could hardly be worse
14. Are you having difficulties driving your car?
Yes, often
Sometimes
No
Not applicable, I do not use a car
15. Do you always fasten your seat belt when you are in a car?
Yes, usually
Yes, sometimes
No
16. How often during the past 4 weeks have you been bothered by any of the following problems?
Rows
Never
Seldom
Sometimes
Often
Always
Fall or dizzy when standing up
Sexual problems
Trouble eating well
Teeth or dentures
Problems using the telephone
Tired or fatigued
17. Have you fallen 2 or more times in the past year?
Yes
No
18. Are you afraid of falling?
Yes
No
19. Are you a smoker?
No
Yes, and I might quit
Yes, but I'm not ready to quit
20. During the past 4 weeks, how many drinks of wine, beer or other alcoholic beverages did you have?
10 or more per week
6-9 per week
2-5 per week
1 drink or less per week
No alcohol at all
21. Do you exercise for about 20 minutes 3 or more days a week?
Yes, most of the time
Yes, some of the time
No, I usually don't exercise this much
22. Have you been given any information to help you with hazards in your house that might hurt you?
Yes
No
23. Have you been given any information to help you with keeping track of your medications?
Yes
No
24. How often do you have trouble taking medicines the way you have been told to take them?
I do not have to take medication
I always take them as prescribed
Sometimes I take them as prescribed
I seldom take them as prescribed
25. How confident are you that you can control and manage most of your health problems?
Very confident
Somewhat confident
Not very confident
I do not have any health problems
How old are you?
65-69
70-79
80 or older
Are you male or female?
Male
Female
Prefer not to say
What is your race? (check one or more than one)
White
Black/African American
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native
Hispanic or Latino origin or descent
Other
Prefer not to say
Submit
Should be Empty: