CARY ADULT MEDICINE

Name * Date of Birth * Today's Date * During the past 4 weeks how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad, or downhearted and blue? During the past 4 weeks has your physical and emotional health limited your social activities with family friends neighbors or groups During the past 4 week how much bodily pain have you generally had? During the past 4 weeks was someone available to help you if you needed and wanted help? Examples (felt nervous, lonely,got sick , needed someone to talk to or needed help caring for yourself) During the past 4 weeks what was the hardest physical activity you could do for at least 2 minutes? Can you go shopping for groceries prepare meals do regular house work without someone's help? Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing , or getting around the house? Can you handle your own money without help? During the past 4 weeks how would you rate your health? Are you having difficulties driving your car or getting lost ? Do you always fasten your seat belt when you are in a car? Have You Fallen two or more times in the past year or have any fears you may fall with an unstable gait? During the past 4 weeks how many drinks of wine beer or other alcoholic beverages did you have? Do you exercise for about 20 minutes 3 or more days a week? How often to do you have trouble taking medications the way you have been told to take them? How confident are you that you can control and manage most of your health problems? Have you had any of the below issues in past several months? In the past several months have you had any of the following? (CHECK ALL THAT APPLY) * Do you have a living will? * Please check box if you have any of the following : * Do you recall year you had your last colonoscopy (Answer Required) * If you are a female do you remember last time you had a mammogram Please describe any change in your medical history since last visit or reply no change What is your current housing situation Where you currently live check any of the following that apply Have you had any transportation issues in the past 12 months? * in the past 12 months has the gas electric or water company threatened to shut off services to your home? * Do you feel safe at home? Are you concerned about any recent changes in your thinking or memory * Do you have more trouble remembering things that have happened recently than you used to *