Pacific Family Medicine, LLP

Medicare Wellness Screening Form

Today's Date * Full Patient Name * Date of Birth *

PLEASE BE SURE TO ANSWER ALL QUESTIONS. ONLY GIVE ONE ANSWER PER QUESTION. Thank you!

1. What is your age?

65-69 70-79 80 or older

2. Are you male or female?

Male Female

3. During the PAST FOUR WEEKS, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad, or downhearted and blue?

Not at all Slightly Moderately Quite a bit Extremely

4. During the PAST FOUR WEEKS, has your physical and emotional health limited your social activities with family, friends, neighbors, or groups?

Not at all Slightly Moderately Quite a bit Extremely

5. During the PAST FOUR WEEKS, how much bodily pain have you generally had?

No pain Very mild pain Mild pain Moderate pain Severe pain

6. During the PAST FOUR WEEKS, was someone available to help you if you needed and wanted help? (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.)

Yes, as much as I wanted Yes, quite a bit Yes, some Yes, a little No, not at all

7. During the PAST FOUR WEEKS, what was the hardest physical activity you could do for at least two minutes?

Very heavy Heavy Moderate Light Very light

8. Can you get to places out of walking distance without help? (For example, can you travel alone on buses or taxis, or drive your own car?)

Yes No

9. Can you go shopping for groceries or clothes without someone's help?

Yes No

10. Can you prepare your own meals?

Yes No

11. Can you do your own housework without help?

Yes No

12. Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house?

Yes No

13. Can you handle your own money without help?

Yes No

14. During the PAST FOUR WEEKS, how would you rate your health in general?

Excellent Very good Good Fair Poor

15. How have things been going for you during the PAST FOUR WEEKS?

Very well; could hardly be better Pretty well Good and bad parts about equal Pretty bad Very bad; could hardly be worse

16. Are you having difficulties driving your car?

Yes, often Sometimes No Not applicable, I do not use a car

17. Do you always fasten your seat belt when you are in a car?

Yes, usually Yes, sometimes

18. How often during the PAST FOUR WEEKS have you been bothered by any of the following problems:

a. Falling or dizzy when standing up?

Never Seldom Sometimes Often Always

b. Sexual problems

Never Seldom Sometimes Often Always

c. Trouble eating well

Never Seldom Sometimes Often Always

d. Teeth or denture problems

Never Seldom Sometimes Often Always

e. Problems using the telephone

Never Seldom Sometimes Often Always

f. Tiredness or fatigue

Never Seldom Sometimes Often Always

19. Have you fallen two or more times in the PAST YEAR?

Yes No

20. Are you afraid of falling?

Yes No

21. Are you a smoker?

No Yes, and I might quit Yes, but I am not ready to quit

22. During the PAST FOUR WEEKS, how many drinks of wine, beer, or other alcoholic beverages did you have?

10 or more drinks per week 6-9 drinks per week 2-5 drinks per week One drink or less per week No alcohol at all

23. Do you exercise for about 20 minutes three or more days a week?

Yes, most of the time Yes, some of the time No, I usually do not exercise this much

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

a. Hazards in your house that might hurt you?

Yes No

b. Keeping track of your medications?

Yes No

25. How often do you have trouble taking medicines the way you have been told to take them?

I do not have to take medicine I always take them as prescribed Sometimes I take them as prescribed I seldom take them as prescribed

26. How confident are you that you can control and manage most of your health problems?

Very confident Somewhat confident Not very confident I do not have any health problems

27. What is your race? (Check all that apply.)

White Black or African American Asian Native Hawaiian or other Pacific Islander American Indian or Alaska Native Hispanic or Latino origin or decent Other

Thank you very much for completing your Medicare Wellness checkup questionnaire.