Medicare Wellness Screening Form
PLEASE BE SURE TO ANSWER ALL QUESTIONS. ONLY GIVE ONE ANSWER PER QUESTION. Thank you!
1. What is your age?
2. Are you male or 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?
4. During the PAST FOUR WEEKS, has your physical and emotional health limited your social activities with family, friends, neighbors, or groups?
5. During the PAST FOUR WEEKS, how much bodily pain have you generally had?
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.)
7. During the PAST FOUR WEEKS, what was the hardest physical activity you could do for at least two minutes?
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?)
9. Can you go shopping for groceries or clothes without someone's help?
10. Can you prepare your own meals?
11. Can you do your own housework without help?
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?
13. Can you handle your own money without help?
14. During the PAST FOUR WEEKS, how would you rate your health in general?
15. How have things been going for you during the PAST FOUR WEEKS?
16. Are you having difficulties driving your car?
17. Do you always fasten your seat belt when you are in a car?
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?
b. Sexual problems
c. Trouble eating well
d. Teeth or denture problems
e. Problems using the telephone
f. Tiredness or fatigue
19. Have you fallen two or more times in the PAST YEAR?
20. Are you afraid of falling?
21. Are you a smoker?
22. During the PAST FOUR WEEKS, how many drinks of wine, beer, or other alcoholic beverages did you have?
23. Do you exercise for about 20 minutes three or more days a week?
24. Have you been given any information to help you with the following:
a. Hazards in your house that might hurt you?
b. Keeping track of your medications?
25. How often do you have trouble taking medicines the way you have been told to take them?
26. How confident are you that you can control and manage most of your health problems?
27. What is your race? (Check all that apply.)
Thank you very much for completing your Medicare Wellness checkup questionnaire.