Medicare Annual Wellness Visit Questionnaire

Medicare Annual Wellness Visit

The Medicare Annual Wellness Visit is a way for our practice to keep you as healthy as possible. If you've had Medicare Part B (Medical Insurance) for longer than 12 months, you can get a yearly "Wellness" visit to develop or update your personalized plan to help prevent disease or disability, based on your current health and risk factors. The yearly "Wellness" visit isn't a physical exam.

Your costs in Original Medicare

You pay nothing for this visit if your doctor or other qualified health care provider accepts assignment The Part B deductible doesn't apply.

However, you may have to pay coinsurance. and the Part B deductible may apply if:

Your doctor or other health care provider performs additional tests or services during the same visit.
Medicare doesn't cover these additional tests or services under this preventive benefit.

If Medicare doesn't cover the additional tests or services , you may have to pay the full amount.

What it is

Your provider will ask you to fill out a questionnaire, called a "Health Risk Assessment," as part of this visit Answering these questions can help you and your provider develop a personalized prevention plan to help you stay healthy. Your visit may include:

A review of your medical and family History.
A review of your current providers and prescriptions.
Height, weight , blood pressure, and other routine measurements .
Personalized health advice•A list of risk factors and treatment options for you.
A screening schedule (like a checklist) for appropriate preventive services.

Signature

Date of Birth

Date

Health Risk Assessment

Patient Name:

Date of Birth

Date

1. Can you get places out of walking distance without help? *For example, can you tavel alone by bus, taxi, or drive your own car?

Yes No

2. Can you shop for groceries or clothes without help?

Yes No

3. Can you prepare your own meals?

Yes No

4. Can you do your own housework without help?

Yes No

5. Can you handle your own money without help?

Yes No

6. Do you need help eating, bathing, dressing, or getting around your home?

Yes No

7. Are you having difficulties driving your car?

No Sometimes Yes, often Not applicable, I do not use car

8. Have you been given any information to help you keep track of your medications)

Yes No

9. How often do you have trouble taking medicines the way you have been told to take them?

I do not have to take medicine I always take them as prescribed Sometimes I take them as prescribed I seldom take them as prescribed

10. During the past 4 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

13. How often in the past 4 weeks, have you had problems using the telephone?

Never Seldom Sometimes Often Always

14. Have you been given any information to help you identify hazards in your house that might hurt you I

Yes No

15. Do you aways fasten your seatbelt when you arc in car?

Yes, usually Yes, Sometimes No

16. Have you had sex in the past 12 months (vaginal, oral or anal)?

Yes No

16. Have you had sex in the past 12 months? (vaginal, oral or anal)?

Yes No

17. Have you ever had a sexually transmitted disease?

Yes No

20.During the past 4 weeks, how would you rate your general health?

Excellent Very good Good Fair Poor

21. How have things been going for you in the past 4 weeks?

Very well

- could hardly be better

Pretty good Good and bad are about equal Pretty bad Very bad

- could hardly be worse

22. 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

23. Over the past 2 weeks, have you experienced having little interest or pleasure in doing things?

Yes No

24 . Over the past 2 weeks, have you been feeling down, depressed or hopeless?

Yes No

25 . A re you a smoker?

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

26. Did you have a drink containing alcohol in the past year?

Yes No

27. Have you fallen two (2) or more times in the past

Yes No

28. Were you injured in any falls in the past year?

Yes No

29. Do you have an Advanced Directive?

Yes No

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