Medicare Annual Wellness Visit Page 6
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6Annual Wellness Visit Pre-Visit Questionnaire - Female
2. Feeling down, depressed or hopeless?
Not at all
Several days
More than half the days
Nearly every day
0
1
2
3
3. Trouble falling or staying asleep, or sleeping too much?
Not at all
Several days
More than half the days
Nearly every day
0
1
2
3
4. Feeling tired or having little energy?
Not at all
Several days
More than half the days
Nearly every day
0
1
2
3
5. Poor appetite or overeating?
Not at all
Several days
More than half the days
Nearly every day
0
1
2
3
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down?
Not at all
Several days
More than half the days
Nearly every day
0
1
2
3
7. Trouble concentrating on things, such as reading the newspaper or watching television?
Not at all
Several days
More than half the days
Nearly every day
0
1
2
3
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?
Not at all
Several days
More than half the days
Nearly every day
0
1
2
3
9. Thoughts that you would be better off dead, or of hurting yourself in some way?
Not at all
Several days
More than half the days
Nearly every day
0
1
2
3
10. Have you ever taken medication or received counseling for depression,
anxiety or any other mood disorder?
Yes
No
This form is a worksheet only, and will not become part of the legal medical record. All information from worksheet should be entered into EMR
electronically.
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