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Medicare Annual Wellness Visit Questionnaire
Name: ______________________________ Date of Birth: _______________Today’s Date: ______________
What over the Counter Medications are you taking, including vitamins and supplements?
What other physicians or providers do you see, and for which problems?
Where do you get your medical supplies? (Diabetes, ostomy supplies, etc)
How do you rate your health? (Circle one) Excellent Good Fair Poor
Do you have trouble hearing the television or radio when others do not?
Do you have to strain or struggle to hear or understand conversations?
Do you have trouble seeing, even with glasses?
Do you have trouble walking?
Do you need help with shopping?
Do you need help climbing stairs?
Do you need help with preparing meals?
Do you need help with bathing?
Do you need help with housework?
Do you need help with dressing?
Do you need help with laundry?
Do you need help with telephone use?
Do you need help with taking medications?
Do you need help with transportation?
Do you need help with managing money?
Do you have trouble concentrating, remembering or making decisions?
Over the past 2 weeks, have you felt down, depressed or hopeless?
Over the past 2 weeks, have you felt little interest or pleasure in doing things?
Do you have a working smoke alarm in your home?
Does your home have loose rugs in the hallway?
Does your home have poor lighting?
Does your home have grab bars in the bathroom?
Does your home have handrails on the stairs?
In the past 12 months, have you fallen?
In the past 6 months, have you experienced leaking of urine?
Do you have an Advance Directive?