Liberty Doctors, LLC

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.

First Name: * Last Name: * Date of Birth: * Today's Date: *

Medicare Health Risk Screening

How would you rate your exercise level? * Are you following any special diets, like maybe: diabetic, vegetarian, vegan or gluten free? * If yes, what diet? Are you able to prepare your own meals? * How many meals do you eat per day? * Do you have trouble with finding transportation? * Would you say you have had any difficulty in your normal daily activities? Like eating, bathing or dressing? * Is there anything in your home that might cause you to fall like maybe throw rugs or poor lighting? * Do you have handrails on any stairs or grab bars in your bathroom? * In the past 4 weeks would you say that your health has been: * Do you have any issues in your normal daily activities because of your eyesight (watching TV, driving...)? * Have you lost 10 or more pounds in the last 6 months without trying? * Do you have any trouble managing your medications on a daily basis? * Do you use any tobacco containing products? * If yes, what kind? Do you use any illicit drugs? * If yes, what kind?

Fall Risk

Have you fallen in the past year? * If yes, how many times? Were you injured as a result of the fall? Do you feel unsteady when you walk? * Are you worried about falling at all? * Do you use a cane/walker? * Do you have to hold on to any furniture while walking or use furniture to stand up? * Do you have trouble stepping onto a curb? * Do you notice any numbness in your feet, or do your steps feel heavy? * Do you take any medications that make you feel lightheaded or more tired than usual? *

Hearing Screening

Does a hearing problem cause you to feel embarrassed when meeting new people? * Does a hearing problem cause you to feel frustrated when talking to members of your family? * Do you have difficulty hearing when someone speaks in a whisper? * Do you feel handicapped by a hearing problem? * Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? * Does a hearing problem cause you to attend religious services less often than you would like? * Does a hearing problem cause you to have arguments with family members? * Does a hearing problem cause you difficulty when listening to TV or radio? * Do you feel that any difficulty with your hearing limits or hampers your personal or social life? * Does a hearing problem cause you difficulty when in a restaurant with relatives or friends? *

Patient Health Questionnaire (PHQ-9)

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

Little interest or pleasure in doing things * Feeling down, depressed, or hopeless * Trouble falling or staying asleep, or sleeping too much * Feeling tired or having little energy * Poor appetite or overeating * Feeling bad about yourself or that you are a failure, or have let yourself or your family down * Trouble concentrating on things, such as reading a newspaper or watching TV * Moving or speaking so slowly that other people could have noticed; or the opposite, being so fidgety or restless that you have been moving around a lot more than usual * Thoughts that you would be better off dead or of hurting yourself in some way * If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *

The Alcohol Use Disorders Identification Test

How often do you have a drink containing alcohol? * How many drinks containing alcohol do you have on a typical day when you are drinking? * How often do you have six or more drinks on one occasion? * How often during the last year have you found that you were not able to stop drinking once you had started? * How often during the last year have you failed to do what was normally expected of you because of drinking? * How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? * How often during the last year have you had a feeling of guilt or remorse after drinking? * How often during the last year have you been unable to remember what happened the night before because of your drinking? * Have you or someone else been injured because of your drinking? * Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? * Have you ever been in treatment for an alcohol problem? *

Preventative Screening

Have you had a Lipid Panel? If yes, date: Have you had a Prostate Screening? (Males Only) If yes, date: Have you had an A1C? If yes, date: Have you had a Prevnar 13 immunization? If yes, date: Have you had a Pneumovax immunization? If yes, date: Have you had a Tetanus Shot? If yes, date: Have you had a Shingles Vaccination? If yes, date: Have you had an Influenza Vaccination? If yes, date: Have you had a Glaucoma test? If yes, date: If you are a Diabetic patient, have you had a Diabetic Eye Exam to screen for Retinopathy? If yes, date: Have you had a Colorectal Cancer Screening? If yes, date: Have you had a Pap Smear? (Females Only) If yes, date: Have you had a Mammogram? If yes, date: Have you had a Bone Density Test? If yes, date: Have you had an Abdominal aortic aneurysm screening? If yes, date:

Additional Comments

Comments:

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