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Medicare Health Risk Assessment

Medicare Health Risk Assessment form

If you are a medicare patient, please complete this form before your yearly wellness exam. This health risk assessment is mandated by the government under the Affordable Health Care Act.

(For example, if you felt very nervous, lonely or blue; got sick and had to stay in bed; needed someone to talk to; needed help with daily chores; or needed help just taking care of yourself.)
(For example, can you travel alone on buses, taxis, or drive your own car?)

18. For the next 6 questions (a through f), indicate how often during the past four weeks have you been bothered by any of the following problems?

24. Have you been given any information to help you with the following:

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