Tidewater Family Medical Care, PC

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MEDICARE WELLNESS CHECK NEW PATIENT DEMOGRAPHICS NEW PATIENT MEDICAL HISTORY

MEDICARE WELLNESS CHECK

Your Name: *

Your Date of Birth: *

Today's Date: *

What is your age? *

65-69

70-79

80 or older

Are you a male or female? *

Male

Female

During the past four weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, or sad? *

Not at all.

Slightly.

Moderately.

Quite a bit.

Extremely.

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.

During the past four weeks, how much bodily pain have you generally had? *

No pain.

Very mild pain.

Mild pain.

Moderate pain.

Severe pain.

During the past four weeks, was someone available to help you if you needed and wanted help? *

Yes, as much as I wanted.

Yes, quite a bit.

Yes, some.

Yes, a little.

No, not at all

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.

Can you get to places out of walking distance without help? *

Yes

(Ex. Can you travel alone alone on buses, taxis, or drive your own car?)

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

Yes

Can you prepare your own meals? *

Yes

Can you do your own housework without help? *

Yes

Due to 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

Can you handle your own money without help? *

Yes

During the past four weeks, how would you rate your health in general? *

Excellent.

Very good.

Good.

Fair.

Poor.

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.

Are you having difficulties driving your car?

Yes, often.

Sometimes.

No.

Not applicable, I do not use a car.

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

Yes, usually.

Yes, sometimes.

No.

In the past four weeks, have you been bothered by any of the following problems? *

Falling or dizzy when standing up.

Sexual problems.

Trouble eating well.

Teeth or denture problems.

Problems using the telephone.

Tiredness or fatigue.

Have you fallen two or more times in the past year? *

Yes

Are you afraid of falling? *

Yes

Are you a smoker? *

No.

Yes, and I might quit.

Yes, but I am not ready to quit.

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.

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.

Have you been given any information to help you with hazards in your house that might hurt you? *

Yes

Have you been given any information to help you with keeping track of your medications? *

Yes

How often do you have trouble taking medicines the way you have been instructed 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.

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.

Thank you very much for completing your Medicare Wellness Checkup. Please either submit this questionnaire via your patient portal account or give to your doctor at your visit.

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