Guillen, Arjona & Medical Associates

As part of the Medicare Annual Wellness Visit, please answer the questions to the best of your abilities

DEMOGRAPHICS

Name * Date of Birth * Gender Race Ethnicity

BEHAVIORAL RISK FACTORS

A. PHYSICAL ACTIVITY

1. How many days a week do you exercise? If you do 2. How would you rate the intensity level of your exercise program?

B. SMOKING

3. Do you currently use cigarettes, cigars or any type of tobacco products? 4. Are you a former smoker or former user of tobacco products? How many packs per day? How many years? When do you quit?

C . ALCOHOL USE

5. During the past 4 weeks, how many drinks of wine, beer, or any alcoholic beverage did you have?

Note for Provider: For 2 or more drinks per week consider doing AUDIT assessment.

D. NUTRITION / DIET

6. On a typical day, how many servings of fruits and vegetables do you eat? 7. On a typical week, how may serving of fried or high fat food (cheese, fatty meat) do you eat? 8. On a typical week, how many servings of fiber or whole grains do you eat?

E. MOTOR / VEHICLE SAFETY

9.Do you wear seat belt when in the car? 10 . Are you having difficulties driving your car?

F. HOME SAFETY

11. Do you have smoke detectors in your house and routinely check the batteries? 12. Do you have a fire extinguisher and know how to use it properly? 13. Are you aware of any hazards in your house which might hurt you?

PSYCHOSOCIAL RISK FACTORS

H. MENTAL WELLNESS

14. During the past 4 weeks, how much you have been bothered by emotional problems such as feeling anxious, depressed, irritable, sad, downhearted or blue? 15. During the past 4 weeks, has your physical or emotional health limited your social activities with family, friends, neighbors, or groups?

PAIN ASSESSMENT

16. During the past 4 weeks, how much bodily pain have you generally had? Location Duration Description What makes it better

SELF ASSESSMENT OF GENERAL HEALTH

17. Are you sexually active? 18. Do you have any sexual problems What type of Sexual Problems? 19. During the past 4 weeks, have you been bother by any of the following problems? Check all that apply 20. On a typical day, how many hours of sleep do you get? 21. During the past 4 weeks, how would you rate your health in general? 22. How confident are you that you can control and managed most of your health problems? 23. During the past 4 weeks, was someone available to help you if you needed and wanted help?

FALL RISK ASSESSMENT

24. Have you fallen in the past year? 25. Do you feel unsteady when walking or standing? 26. Are you worry about falling?

FUNCTIONAL ASSESSMENT

ACTIVITIES OF DAILY LIVING

Bathing Dressing Grooming Toileting Mouth Care Eating Transfer from Bed to Chair Walking Going up or down stairs

INSTRUMENTAL ACTIVITIES OF DAILY LIVING

Meal preparation Shopping Using phone or internet Housekeeping Laundry Handling Medications Handling Finances Who Provide you help? Comments about Functional Assessment

ADDITIONAL QUESTIONS

27. In the past 12 months, have you been in the emergency room 2 of more times? 28. In the past 12 months, have you been admitted to the hospital? If yes, what Hospital and for what reason? 29. Have you had any changes in thinking, remembering, or making decisions? 30. Do you sometimes run out of money to pay for rent, food, bills, and medicines?

Next is providers notes, comments and/or summary. Please go to next section.

Provider's Notes

PROVIDERS AND DME SUPPLIERS LIST

Please write down the names and specialties of other providers you have seen in the past 12 months.

Other Providers List

Please write down the list of the medical supply stores (DME) you have used in the past 12 months.

DME supplier list

MEDICATION AND SUPPLEMENTS LIST

Please write down the list of all the medications or supplements you currently take.

Medication and supplement list

FAMILY HISTORY

Does any of the following medical conditions run in your family? Check all that may apply Family History

PROBLEM LIST

Do you have any of the following medical conditions? Please check all that may apply Please write down any other medical conditions you have Date form is filled *

YOU HAVE COMPLETED THE QUESTIONNAIRE. THANK YOU FOR YOUR COOPERATION!

Notes and commends by Provider Date form is Reviewed by Provider Provider Reviewing HRA