MEDICARE WELLNESS CHECK-UP

Name:

DOB:

Date

HEALTH RISK ASSESSMENT

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

Age

Are you

Male Female

Are there other physicians/specialist you follow with on a regular basis?

Yes No

If so please list them here: (please include eye doctor, dermatologist and gynecologist if you follow regularly with those physicians)

Are you a smoker?

No Yes and I might quit Yes but I am not ready to quit

If you are a current or former smoker:

What age did you start smoking?

On average how may packs a day did you or do you smoke?

If you are a former smoker, what age did you quit?

Over the last 2 weeks have you felt little interest or pleasure in doing things?

Yes No

Over the last 2 weeks have you felt down, depressed or hopeless?

Yes No

Did you have a drink with alcohol in it in the last year?

Yes No

During the past 4 weeks, how much bodily pain have you generally had?

No pain Very mild pain Mild pain Moderate pain Severe pain

Have you fallen within the last 12 months?

Yes No

Are you afraid of falling?

Yes No

Do you feel dizzy when standing up?

Never Seldom Sometimes Often Always

Do you use equipment to help you walk or get around?

Yes No

If so what type of equipment do you use?

Have you seen an eye doctor in the last year?

Yes No

Do you have trouble hearing?

Yes No

During the past 4 weeks, was someone available to help you if you have 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

How often do you have trouble taking medications the way you have been told to take them?

I do not take any medicine I always take them as prescribed Sometimes I take them as prescribed I seldom take them as prescribed

How confident are you that you can control and manage most of your health problems?

Very confident Somewhat confident Not very confident I do not have any health problems

Do you have a living will, advance directives, or healthcare surrogate/medical power of attorney?

Yes No

If so, which of the above do you have?

Do you take any vitamins or supplements?

Yes No

If so,. please list them:

What is your race? (mark all that apply)

White

Black/African American

Asian

Native Hawaiian/Other Pacific Islander

American Indian/Alaskan Native

Hispanic or Latino origin or descent

Other

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