Medicare Wellness Form - Burns Family Practice

Medical Wellness Form

Burns Family Practice
PLEASE COMPLETE THE PHQ-9 AND GAD-7
Name*

First NameLast Name
Date*

MonthDayYear
Date

PHQ9 - Over the last two weeks how often have you been botheredby the following problems? *

	0 - Not at all	1 - Several days	2 - More than half the days	3 - Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way

Severity Score:
- Mild Depression: 5-10
- Moderate Depression: 10-18
- Severe Depression: 19-27
What was your score?*
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult

Estimated Date of Last Screening:*

	Date
Last Colon Cancer Screening (up to 75 y.o)
Last mammogram (up to 75 y.o.)
Last PAP smear (up to 75 y.o.)
Last Low Dose CT (if smoker or history)
Last Bone Density

Estimated Date of Last Vaccine:*

	Date
Pneumonia (1 after 65)
Shingles (2 after 50)
Flu Vaccine (yearly Oct-May)
Tetanus (every 10 years)
COVID (yearly booster)
RSV (1 after 75)