Annual Wellness Questionnaire

Please check the response below that best corresponds with your answer to each question. This form helps guide your provider to address your concerns and questions during your visit.

Name

First Name Last Name

Date of Birth

Date

Date Filled Out

Date

1) During the past four weeks, how would you rate your health in general?

Excellent Very good Good Fair Poor

2) On a scale from 1-10, with 1 being the least confident and 10 being the most confident, how confident are you that you can control and manage most medical problems if they arise?

3) Do you always fasten your seat belt when you are in a car?

Yes No

4) Are you a smoker?

Yes No

5) Have you fallen two or more times in the past year?

Yes No

6) Do you exercise for 20 minutes over the course of a day, 3 or more days a week?

Yes, most of the time No, I usually do not exercise this much

7) In the past 4 weeks, how often have you been bothered by the following:

Never

Sometimes

Always

Falling or Dizziness when you stand up

Sexual problems

Trouble eating well

Difficulty preparing meals

Teeth or denture problems

Trouble hearing or using the telephone

Memory problems

Trouble taking medications

Difficulty shopping

Trouble maintaining your home

Trouble managing money

Trouble driving your car or with transportation

Bodily pain or health problems that have limited your social activities with family or friends or other groups

8) 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 No

9) How confident are you that you could find someone to help you with any of these problems if you needed it?

Very confident Somewhat confident Less confident Not confident

10) Over the last two weeks, how often have you been bothered by any of the following problems?

Not at all

Several days

More than half the days

Nearly every day

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling asleep, staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself, or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching TV

Moving or speaking so slowly that other people could have noticed, or the opposite - being fidgety or restless

Thoughts that you would be better off dead, or of hurting yourself.

10) If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult Somewhat difficult Very difficult Extremely difficult

11) If you checked off any problems, was someone available to you for emotional support?

Yes, as much as I wanted Yes, some No, I could use more support

12) How often did you have a drink containing alcohol in the past year?

Never (skip the last two questions) Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week

13) How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?

1-2 3-4 5-6 7-9 >10

14) How often did you have 6 or more drinks on one occasion in the past year?

Never Less than monthly Monthly Weekly Daily or almost daily

Annual Wellness Questionnaire

Total Score