Medicare Annual Wellness Visit Forms

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

Your Name

Today’s Date

Your Date of Birth

1. What is your age?

18-64

65-69

70-79

80 or older

2. Are you a male or a female?

Male

Female

3. During the past four weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad, or downhearted and blue?

Not at all

Slightly

Moderately

Quite a bit

Extremely

4. During the past four weeks, has your physical and emotional health limited your social activities with family friends, neighbors, or groups?

Not at all

Slightly

Moderately

Quite a bit

Extremely

5. During the past four weeks, how much bodily pain have you generally had?

No pain

Very mild pain

Mild pain

Moderate pain

Severe pain

6. During the past four weeks, was someone available to help you if you needed and wanted help? (For example, if you felt very nervous, lonely, or blue; got sick and had to stay in bed; needed someone to talk to; needed help with daily chores; or needed help just taking care of yourself.)

Yes, as much as I wanted.

Yes, quite a bit.

Yes, some.

Yes, a little.

No, not at all.

7. During the past four weeks, what was the hardest physical activity you could do for at least two minutes?

Very heavy

Heavy

Moderate

Light

Very light

8. Can you get to places out of walking distance without help? (For example, can you travel alone on buses or taxis, or drive your own car?)

Yes

9. Can you go shopping for groceries or clothes without someone’s help?

Yes

10. Can you prepare your own meals?

Yes

11. Can you do your housework without help?

Yes

12. Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house?

Yes

13. Can you handle your own money without help?

Yes

14. During the past four weeks, how would you rate your health in general?

Excellent

Very good

Good

Fair

Poor

15. How have things been going for you during the past four weeks?

Very well; could hardly be better.

Pretty well.

Good and bad parts about equal.

Pretty bad.

Very bad; could hardly be worse.

16. Are you having difficulties driving your car?

Yes, often.

Sometimes.

No.

Not applicable, I do not use a car.

17. Do you always fasten your seat belt when you are in a car?

Yes, usually.

Yes, sometimes.

No.

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

Falling or dizzy when standing up.