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Medicare Wellness Health Risk Assessment
Name
*
First Name
Middle Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
List all care providers outside of Circle Care Center (including specialists, eye doctors, naturopaths, etc.)
Over the past 4 weeks, how do you rate your overall health?
Excellent
Good
Fair
Poor
Psychosocial Health
Please select one response for each question
In the past 2 weeks, how often has the following bothered you?
Rows
Not at all
Several Days
More than half the days
Nearly every day
Feeling stress over health, relationships, or work
Body pain
Feeling anger
Little interest or pleasure in doing things
Health and Habits
Please select one response for each question
In the past week, how many days did you exercise?
Please Select
0
1
2
3
4
5
6
7
How intense was your typical exercise?
Light (stretching or slow walking)
Moderate (a brisk walk)
Heavy (jogging or swimming)
Very Heavy (fast running or stair climbing)
Not currently exercising
How do you rate your nutrition?
Excellent
Good
Fair
Poor
How would you describe the condition of your mouth and teeth, including false teeth or dentures?
Excellent
Good
Fair
Poor
Do you have trouble hearing people speak?
Yes
No
Do you always use a seatbelt in the car?
Yes
No
Do you have a fire extinguisher in your home?
Yes
No
Do you have a smoke detector in your home?
Yes
No
Function and Mobility
Please select one response for each question
How much difficulty do you have with the following activities?
Rows
I can do it by myself
I need some help to do it
I cannot do this; another person needs to do it for me
Preparing food and eating
Bathing yourself
Getting dressed
Using the toilet
Moving around from place to place
Shopping
Using the telephone
Housekeeping
Laundry
Driving or using transportation
Managing own finances
Taking your own medications
Do you use any devices? (Select all that apply)
Cane
Walker
Wheelchair
Crutches
Special utensils
Devices used for dressing (Button hook, zipper pull, etc.)
None
In the past year, have you fallen or had a near fall?
Yes
No
Are you afraid of falling?
Yes
No
Signs of Memory Loss
Please select one response for each question
Have you experienced any memory issues or problems with thinking?
Yes
No
Have family members, friends, caretakers, or others raised concerns about your memory?
Yes
No
Have you received any of these tests in the past year? (Select all that apply)
Cholesterol or diabetes blood test
Bone density tests
Cancer screening like colonoscopy or mammogram
Heart test (ECG or Echo)
Advance Care Planning
Please select one response for each question
Do you currently have a POLST form? (Physician Orders for Life-Sustaining Treatment)
Yes
No
Not sure
Do you currently have a living will / advance directive?
Yes
No
Not sure
Do you currently have a Durable Power of Attorney for Medical Affairs (someone to make medical decisions for you in the event that you are unable to)
Yes
No
Not sure
Do you want to discuss advance care planning at your wellness visit?
Yes
No
Submit
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