Healthwise Internal Medicine

For each question, select the response that most appropriately reflects your feelings and/or situation from the drop-down menu.

First and Last Name Age * Sex * During the last MONTH, have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad, downhearted and blue? During the last MONTH, has your physical and emotional health limited your social activities with family, friends, neighbors, or groups? During the last MONTH, how much bodily pain have you had? During the last MONTH, was someone available to help you if you needed and wanted help when you had any of these feelings: you felt very nervous, lonely or blue, got sick and had to stay in bed, needed someone to talk to or help with chores, or help just taking care of yourself? During the past MONTH, what was the hardest physical activity you could do for at least 2 minutes? Can you go places out of walking distance without help e.g. traveling alone on buses or taxis or drive your own car? Can you go shopping or purchase groceries without assistance from others? Can you prepare your own meals? Can you do your housework without help? Due to any health problems, do you need the hep of another person with your personal care needs such as eating, bathing, dressing, or getting around the house? Can you handle your own money without help? During the past MONTH, how would you rate your health in general? How have things been going for you during the past MONTH? Are you having difficulties driving your car? Do you always fasten your seat belt when you are in the car? How often over the past MONTH have you fallen or felt dizzy? How often over the past MONTH have you had sexual problems? How often over the past MONTH have you had trouble eating? How often over the last MONTH have you had trouble eating? How often over the last month have you had problems with your teeth or dentures? How often over the last MONTH have you had problems using the telephone? How many times over the last MONTH have you felt tiredness or fatigue Have you fallen 2 or more times in the past YEAR? Are you afraid of falling? Are you a smoker? During the past MONTH, how many drinks or wine, beer, or other alcoholic beverages did you have? Do you exercise for more than 20 minutes 3 or more days a week? Have you been given any information to help you with avoiding hazards in your home? Have you been given any information to help you with keeping track of your medications? Over the past 2 WEEKS, how often have you had little to not interest or please in doing things? Over the past 2 WEEKS, how often have you felt down, depressed or hopeless? Does you home have throw rugs, poor lighting, or a slippery bathtub or shower? Does your home LACK grab bars in the bathroom, handrails on stairs and steps? Does your home LACK functioning smoke alarms? How confident are you that you can control and manage most of your health problems? What is your race? Check all the apply. Please identify your current Providers and Suppliers