Annual Help Risk Assessment (65+)

Please correct the errors described below.

Please complete this checklist before seeing your doctor or nurse. Your responses will help you receive the best health and health care possible.

18. How often during the past four weeks have you been bothered by any of the following problems?

24. Have you been given any information to help you with the following:

Thank you very much for completing your Medicare Wellness Checkup. Please give the completed checkup to your doctor or nurse.

Your information will be encrypted.