Medicare Annual Wellness Visit Page 3
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4Name: __________________________________
Date of Birth: _____________
Please provide the most recent occurrence of the following Preventative
Care services:
Preventative
Name of Doctor,
Date performed
Normal /
Care Service
or Office Group
Abnormal results
Colonoscopy or
Flexible
Sigmoidoscopy
Mammogram
Pap Smear
DEXA ( Bone
Density Testing
Please answer the following questions:
1. During the past month have you often been bothered by feeling
□ Yes □ No
down, depressed, or hopeless?
2. During the past month, have you often been bothered by lack of
□ Yes □ No
interest or pleasure in doing things?
3. Because of a health or memory problem do you have difficulty
□ Yes □ No
with bathing or showering?
4. Because of a health or memory problem do you have any difficulty
□ Yes □ No
managing your money such as paying bills and keeping track of
expenses?
5. Because of a health or memory problems do you have any
□ Yes □ No
difficulty with walking several blocks?
6. Because of a health problem do you have any difficulty with
□ Yes □ No
pushing or pulling large objects like a living room chair?
7. Because of a health or memory problem do you have any difficulty
□ Yes □ No
with dressing yourself?
8. Because of a health or memory problem do you have any difficulty
□ Yes □ No
with toileting; such as transferring yourself to the toilet, cleaning
yourself or having incontinence of stool or urine?
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