Fillable Medicare Annual Wellness Visit Questionnaire What over the (Sutter Health )

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Medicare Annual Wellness Visit Questionnaire What over the (Sutter Health )

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The Medicare Annual Wellness Visit Questionnaire What over the (Sutter Health ) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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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?
Medications/Vitamins/Supplement
Reason
What other physicians or providers do you see, and for which problems?
Specialist
Problem
Where do you get your medical supplies? (Diabetes, ostomy supplies, etc)
Medical Supplier
Problem
How do you rate your health? (Circle one) Excellent Good Fair Poor
Hearing/Vision Evaluation:
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?
Yes
Yes
Yes
No
No
No
Functional Evaluation:
Do you have trouble walking?
Yes
Do you need help with shopping?
Do you need help climbing stairs?
Yes
Do you need help with preparing meals?
Do you need help with bathing?
Yes
Do you need help with housework?
Do you need help with dressing?
Yes
Do you need help with laundry?
Do you need help with telephone use?
Yes
Do you need help with taking medications?
Do you need help with transportation?
Yes
Do you need help with managing money?
Do you have trouble concentrating, remembering or making decisions?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Depression Questionnaire:
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?
Yes
Yes
No
No
Home Safety:
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?
Do you live alone?
In the past 12 months, have you fallen?
In the past 6 months, have you experienced leaking of urine?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Advance Directive:
Do you have an Advance Directive?
Yes
No
July 2016
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Medicare Annual Wellness Visit Questionnaire What over the (Sutter Health )

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Completed 21 December 2020

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