Medicare Patient Health Risk Assessment (Hra) & History Page 2
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2Medicare Patient Health Risk Assessment (HRA) & History
Name:
Date of Birth:
F. Current Medications/Supplements: List all current prescription and non-prescription medicines, vitamins, herbs, etc.
Name
Date last
Name
Date last
filled
filled
1.
6.
2.
7.
3.
8.
4.
9
5.
10.
Medication allergies: _____________________________________________________________
Other allergies: __________________________________________________________________
G. Functional Ability/Safety Screening
1. Do you feel unsteady when you walk?
Yes
No
2. Have you recently fallen?
Yes
No
3. Do you need help with eating, getting dressed, grooming, bathing, walking or using the toilet?
Yes
No
4. Does your home have rugs in the hallways, grab bars in the bathrooms, hand-rails on the stairs,
Yes
No
proper lighting, smoke and carbon monoxide detectors?
5. Do you need help with the phone, transportation, shopping, preparing meals, house-work, laundry,
Yes
No
medications or managing money?
6. Have you noticed vision impairment?
Yes
No
H. Depression Screening Questionnaire: Over the last 2 weeks, how often have you been bothered by any of the
following problems?
Not at all
Several
More than
Nearly
(0 points)
days
half the days
every day
(1 point)
(2 points)
(3 points)
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
3. Trouble falling or staying asleep, or sleeping too much.
4. Feeling tired or having little energy.
5. Poor appetite or overeating.
6. Feeling bad about yourself—or that you are a failure or have let
yourself or your family down.
7. Trouble concentrating on things, such as reading the newspaper or
watching television.
8. 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.
9. Thoughts that you would be better off dead, or of hurting yourself in
some way.
10. 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?
*Healthcare professional will evaluate answers for the questionnaire.
_________________________________
Patient (sign & date):
Provider only (sign & date): ____________________________
Office Staff only: _____________
Page 2 of 2
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