Medicare Wellness

Medicare Wellness

Pre-Visit Questionnaire
This is your Medicare Health Risk Assessment or HRA that is an integral part of your Annual Wellness Visit (AWV), or your initial Welcome to Medicare Visit (called an IPPE). This is to determine any risks or barriers to your health going forward. These should be done every year, and there is no charge to you for these Medicare Appointments. Please note that these appointments are primarily to determine your risks, and aren't for chronic care management, or acute illnesses.
Name

First NameLast Name
Date of Birth

MonthDayYear
GENERAL HEALTH
How is your overall health?*

ExcellentGoodFairPoorI don't know
How many different prescriptions are you taking?*

0-34-67-1010+I don't know
Do you take all of your medications as prescribed?*

YesNoSometimesI don't take medicationAlmost never
How is the health of your teeth and mouth?*

ExcellentGoodFairPoorI don't know
Do you have a dentist that you visit regularly?*

YesNoI don't know
How many times in the last six months were you admitted to the hospital?*

01-23-45+I don't know
TOBACCO AND ALCOHOL USE

HCPCS CODES 99406, G0442
Do you use any tobacco products?*

Yes.No
Are you interested in quitting tobacco?*

YesNoI don't use tobacco
How many times in the past year have you had 4 or more alcoholic drinks in a day?*

None1-23-45+
Are you interested in receiving help for any other type of substance abuse?*

YesNo
NUTRITION
How many servings of fruits and vegetables do you usually eat each day?*

None1-23-45+I don't know
How many servings of fiber or whole grain foods do you usually eat each day?*

None1-23-45+I don't know
How many servings of meat, fish, or other protein do you usually eat each day*

None1-23-45+I don't know
How many servings of fried or high=fat goods do you usually eat each day?*

None1-23-45+I don't know
How many servings of of sugar-sweetened drinks do you usually have each day*

None1-23-45+I don't know
PHYSICAL ACTIVITY
How many days a week to your exercise?*

None1-23-45+I don't know
On the days that you exercised, how long did you exercise?*

0-30 minutes30 minutes to 1 hourMore than 1 hourI don't knowI don't exercise
How intense is your exercise?*

Light (stretching, slow walking)Moderate (brisk walking)Heavy (jogging, swimming)Very heavy (running fast)I don't knowI don't exercise
SLEEP
How many hours of sleep do you usually getl?*

0-34-67-1010+I don't know
Do you snore or has anyone told you that you snore?*

YesNoI don't know
In the past seven days, how often have you felt sleepy during the day?*

OftenSometimesAlmost neverNeverI don't know
FUNCTIONAL STATUS ASSESSMENT

CPT II CODE 1170F
Instrumental activities of daily living
Which of the following can you do on your own without help*

Shop for groceriesUse the telephoneHouseworkHandle financesDrive/use public transportationMake mealsTake medicationsNone
Activities of daily living
Which of the following can you do on your own without help?*

BathDressEatWalkTransfer (in/out of chairs, beds, etc)Use the restroomNone
Many people experience leakage of urine, also called urinary incontinence. in the past six months, have you experienced leaking of urine?*

YesNoI don't know
Ambulation status
How long can you walk or move around?*

0-5 minutes5-15 minutes15-30 minutesMore than 1 hourI don't know
Which of these assistive devices to you use?*

CaneWalkerWheelchairCrutchesOtherNone
Do you have any trouble with your balance?*

YesNo
Have you fallen in the past six months?*

YesNo
Sensory ability
Do you have problems with vision?*

Yes.No.I don't know
Do you use eyeglasses or contact lenses?*

Yes.No.I don't know
Do you have problems hearing?*

YesNoI don't know
Do you use hearing aids or other devices to help you hear?*

YesNoI don't know
PAIN ASSESSMENT

CPT II CODES 1125F, 1126F
In the past two weeks, how often have you felt pain?*

Almost all of the timeMost timesSometimesAlmost neverNo pain
If you've had pain, where?

Use the "Pen", the third icon from the left. Eraser is the fourth icon on the left. (Don't click the arrows or the "X", you may lose your work)
How to you treat the pain?*

MedicationRestHeat or coldTherapyOtherNo treatment planNo pain
Rate your worst pain in the past 2 weeks, on a scale of 0-10, with 0 being no pain, and 10 being the worst pain?*

12345678910
HOME/SAFETY
What is your living situation?*

AloneWith my spouse or other familyWith a friend or roommageIn a nursing home or assisted living facility/homeI don't have a place to live.Other
Does your home have working smoke alarms?*

YesNoI don't knowN/A
Do you fasten your seatbelt in vehicles?*

YesNoI don't ride in vehicles
If there are guns in your residence, are they locked with the ammunition secured separately?*

YesNoI don't have guns
DEPRESSION - (PHQ-9)

HCPCS CODE G0444

In the last two weeks, how often have you been bothered by any of the following problems?*

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you're a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed or have you been fidgety or restless that you've been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself
If you checked off any problems in this section, 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?

SOCIAL/EMOTIONAL SUPPORT
Which of the following applies to you?*

I have a supportive familyI have supportive friendsI participate in church, clubs or other group activitiesNone
How often do you get out and meet with family and/or friends?*

OftenSometimesAlmost neverNever
ADVANCE DIRECTIVES

CPT II CODES 1157F, 1158F, HCPCS CODE S0257
Do you have a health care power of attorney or a living will*

YesNoI don't know
Would you like more information on a power of attorney or a living will*

YesNo
MEDICATIONS (PRESCRIPTIONS, VITAMINS, OVER THE COUNTER)

CPT II CODE 1159F, 1160F

Medications

	Name	Dose	Times Per Day	Date started	Condition Treated
1
2
3
4
5
6
7
8
9
10

SELF AND FAMILY MEDICAL HISTORY

Mark the columns that apply*

	No or Unknown	Self	Parent	Brother/Sister	Child
Congestive Heart Failure
Diabetes
COPD or Asthma
Hypertension
Stroke
Kidney disease
Bipolar disorder or schizophrenia
Breast Cancer
Cervical Cancer
Prostate Cancer
Colon or GI Cancer
Other or Unknown Cancer

OTHER HEALTH CARE PROVIDERS YOU'VE SEEN IN THE PAST 2 YEARS

Specialty

	Provider name	Date last seen
Cardiologist
Pulmonologist
Eye doctor
Endocrinologist
Physical Therapist
Gynecologist
Dermatologist
Ear, nose and throat (ENT)
Oncologist
Pain doctor
Surgeon
Gastroenterologist
Oncology/Hematology
OTHER 1
OTHER 2
OTHER 3

ALLERGIES (DRUG, FOOD, ENVIRONMENT)

IF NONE, ENTER "NONE" ON LINE #1

	LIST HERE
1
2
3
4
5
6
7
8
9
10

By clicking "Submit" below, this questionnaire will be securely routed to your provider for your upcoming Medicare Wellness Visit, and will be reviewed with you.
Your Provider:*
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Email*
example@example.com
Contact number (optional)
Please enter a valid phone number.
If you have an Advanced Directive, please bring it with you to your Wellness Appointment, we will add it to your medical record.
If you do NOT have an Advanced Directive, would you like to create one?
Should be Empty:

Medicare Wellness

GENERAL HEALTH

TOBACCO AND ALCOHOL USE

NUTRITION

PHYSICAL ACTIVITY

SLEEP

FUNCTIONAL STATUS ASSESSMENT

Instrumental activities of daily living

Activities of daily living

Ambulation status

Sensory ability

PAIN ASSESSMENT

If you've had pain, where?

HOME/SAFETY

DEPRESSION - (PHQ-9)

SOCIAL/EMOTIONAL SUPPORT

ADVANCE DIRECTIVES

MEDICATIONS (PRESCRIPTIONS, VITAMINS, OVER THE COUNTER)

SELF AND FAMILY MEDICAL HISTORY

OTHER HEALTH CARE PROVIDERS YOU'VE SEEN IN THE PAST 2 YEARS

ALLERGIES (DRUG, FOOD, ENVIRONMENT)