Medicare Annual Wellness Visit (Page 4 of 4) in pdf

Medicare Annual Wellness Visit Page 4

Name: __________________________________

Date of Birth: _____________

9. Do you feel handicapped by a hearing problem?

□ Yes □ No

10. Are emergency numbers kept by the phone and regularly

□ Yes □ No

updated?

11. If there are firearms in your home are they stored unloaded and

□ Yes □ No

securely locked?

□ Not

applicable

12. Are all household members aware of the dangers of smoking,

□ Yes □ No

especially in bed?

13. Are working smoke alarms and fire extinguishers available for

□ Yes □ No

use?

14. Do all household members know how to use the smoke alarms

□ Yes □ No

and fire extinguishers?

15. Have throw rugs been removed, or fastened down?

□ Yes □ No

16. Are all electrical cords in working order, easily seen and not run

□ Yes □ No

under carpets or around nails?

17. Are non-slip mats in all bathtubs and showers?

□ Yes □ No

18. Do all stairways, bathtubs, and toilets have a railing or a

□ Yes □ No

banister?

19. Are doorways, halls, and stairs free of clutter?

□ Yes □ No

20. Are sidewalks and all outdoor steps clear of tools, toys, and

□ Yes □ No

Medicare Annual Wellness Visit Page 4