ANNUAL HEALTH RISK ASSESSMENT

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

Today's Date

Your Name

Your Date of Birth

HEARING

Do you use a device, such as hearing aid or assistive listening device to help with hearing?

YES NO

Do issues with your hearing cause difficulty in your social life or ability to hear emergency sirens/smoke alarms?

YES NO

NUTRITION

Do issues with your hearing cause difficulty in your social life or ability to hear emergency sirens/smoke alarms?

YES NO

Do you have difficulty eating, such as chewing, loose or missing teeth, or swallowing?

YES NO

Do you feel that you eat a well-balanced, healthy diet (including whole grains, fruit, vegetables, and limit fats)?

YES NO

HOME SAFETY

Do you have access to up-to-date emergency numbers?

YES NO

Are working smoke alarms and fire extinguisher(s) available for use?

YES NO

Are firearms stored, unloaded, and securely locked?

YES NO Doesn’t apply to me

Do all stairways have a railing or banister?

YES NO Doesn’t apply to me

Is there anything on your floor that could cause you to slip or fall, like rugs, cords, mats, etc.?

YES NO

HEALTH STATUS

Do you have difficulties driving?

YES NO Doesn’t apply to me

Do you wear a seatbelt?

YES NO

Do you need an assistive device for mobility, such as a cane, walker, wheelchair, or motorized device?

YES NO

Do you have problems with leaking urine or making it to the bathroom in time?

YES NO

Have you experience physical or mental abuse in your home environment?

YES NO

In the last 6 months, have you been to the emergency room or hospitalized?

YES NO

In the last 4 weeks have you had any concerns about your health?

YES NO

What is your current living situation?

At home independently At home, with family care At home, with 24-hr care Assisted living Extended care facility

In the past 7 days, did you need help from others to perform everyday activities, such as eating, getting dressed, grooming, bathing, walking, or using the toilet?

YES NO

In the past 7 days, did you need help from other to take care of things such as laundry, housekeeping, banking, shopping, using the telephone, food preparation, transportation, or taking you medications?

YES NO

FALL RISK

Are you taking or are you prescribed any opioid-type pain medications, such as those containing tramadol, hydrocodone, codeine, oxycodone, fentanyl, methadone, or buprenorphine?

YES NO

If yes, do you have routine follow ups with the provider who is prescribing it?

YES NO

Have you had two or more falls in the past year?

YES NO

Have you have one or more falls with injury in the past year?

YES NO

Do you have fear of falling?

YES NO

ADVANCED CARE PLANNING

Do you have an Advance Directive (living will, medical durable power of attorney, or out-of-hospital DNR)?

YES NO

If yes, which type?

Do you have the most recent copy on file with your doctor’s office?

YES NO

Who is your medical durable power of attorney?

Would you like to receive more info on Advance Directives?

YES NO

PAIN

Over the past 7 days, how much did pain interfere with your day-to- day activities?

Not at all Somewhat Quite a bit Very much

MEDICAL SUPPLIES AND EQUIPMENT

Please list any equipment and/or medical supplies that your use or have:

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