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Available Forms

Carolina Family Medicine Informed Consent Carolina Family Medicine New Patient Form Charles Towne Pediatrics Informed Consent Charles Towne Pediatrics New Patient Form Charleston Adults and Geriatrics Informed Consent Charleston Adults and Geriatrics New Patient Form Daniel Island Family Medicine Informed Consent Daniel Island Family Medicine Medicare AWV Form Dr. Heather Dawson- Liberty Doctors Informed Consent Dr. Heather Dawson- Liberty Doctors Informed Consent Dr. Heather Dawson- Liberty Doctors New Patient Form Dr. Jeffrey Akhtar- Liberty Doctors Informed Consent Dr. Jeffrey Akhtar- Liberty Doctors New Patient Form Dr. Laura Lee Kinney Medicare AWV Form Dr. Laura Lee Kinney- Liberty Doctors Informed Consent Dr. Laura Lee Kinney- Liberty Doctors New Patient Form Dr. Monica Lominchar- Liberty Doctors Informed Consent Dr. Monica Lominchar- Liberty Doctors New Patient Form Family First Medical Care Informed Consent Family First Medical Care Medicare AWV Form Family First Medical Care New Patient Form Hope Clinic- Moncks Corner Informed Consent Hope Clinic- Moncks Corner New Patient Form Hope Clinic- North Charleston Informed Consent Hope Clinic- North Charleston New Patient Form Liberty Doctors Informed Consent Liberty Doctors Medicare AWV Form Liberty Doctors New Patient Form Medicare AWV Form Mobile Medical Consultants Informed Consent Mobile Medical Consultants Informed Consent Mobile Medical New Patient Form North Berkeley Family Care Medicare AWV Form North Berkeley Family Care New Patient Form Simple Medicine Informed Consent Simple Medicine New Patient Form South Strand Internists/Surfside Beach Informed Consent South Strand Internists/Surfside Beach Urgent Care New Patient Form South Strand Urgent Care Informed Consent Springhall Family Practice Informed Consent Springhall Family Practice Informed Consent Springhall Family Practice Medicare AWV Form Springhall Family Practice New Patient Form Strand Urgent Care Informed Consent TEST New Patient Form Tiffany Pediatrics Informed Consent Tiffany Pediatrics Informed Consent Tiffany Pediatrics New Patient Form
Springhall Family Practice Medicare AWV Form

Medicare Annual Wellness Visit Questionnaire

Please complete the following assessment PRIOR to your Annual Wellness Visit. Your provider will review this assessment with you during your visit.

Questions marked with a (*) are required and must be answered before you can submit the assessment.

Medicare Health Risk Screening

Fall Risk

Hearing Screening

Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

The Alcohol Use Disorders Identification Test

Preventative Screening

Additional Comments

Thank you for completing this questionnaire. Please click Submit Form when you are finished.

* Required field