• 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.

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  • GENERAL HEALTH

  • TOBACCO AND ALCOHOL USE

    HCPCS CODES 99406, G0442
  • NUTRITION

  • PHYSICAL ACTIVITY

  • SLEEP

  • FUNCTIONAL STATUS ASSESSMENT

    CPT II CODE 1170F
  • Instrumental activities of daily living

  • Activities of daily living

  • Ambulation status

  • Sensory ability

  • PAIN ASSESSMENT

    CPT II CODES 1125F, 1126F
  • 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)
  • HOME/SAFETY

  • DEPRESSION - (PHQ-9)

    HCPCS CODE G0444
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  • SOCIAL/EMOTIONAL SUPPORT

  • ADVANCE DIRECTIVES

    CPT II CODES 1157F, 1158F, HCPCS CODE S0257
  • MEDICATIONS (PRESCRIPTIONS, VITAMINS, OVER THE COUNTER)

    CPT II CODE 1159F, 1160F
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  • SELF AND FAMILY MEDICAL HISTORY

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

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  • ALLERGIES (DRUG, FOOD, ENVIRONMENT)

    IF NONE, ENTER "NONE" ON LINE #1
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  • 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.

     
     
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  • If you have an Advanced Directive, please bring it with you to your Wellness Appointment, we will add it to your medical record.

     
     
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