Medicare Annual Wellness Visit Page 2
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6Name_____________________________________________________
Date______________
Have you developed any other health issues since you were last seen? YES NO
If yes, please describe_____________________________________________________________________
_____________________________________________________________________________________________
Have you fallen in the last year?
YES
NO
If so, how many times_______
Do you feel unsteady walking?
YES
NO
Do you need an assistive device to walk (cane or walker)?
YES
NO
Do you have problems with urinary incontinence?
YES
NO
Do you have problems with bowel incontinence?
YES
NO
Have you seen an eye doctor in the last year?
YES
NO
Do you wear glasses or contacts?
YES
NO
Do you wear hearing aids?
YES
NO
Do you see a dentist at least once yearly?
YES
NO
Do you wear dentures?
YES
NO
Do you have an advanced directive (living will)?
YES
NO
If Yes, where is it located? ____________________________________
Do you feel you have memory problems?
YES
NO
Do family members worry about your memory?
YES
NO
Do you feel down, depressed, or hopeless?
YES
NO
Do you have little interest in doing things?
YES
NO
Do you live alone?
YES
NO
Do You Drive?
YES
NO
Have you been involved in a motor vehicle accident recently? YES
NO
How many alcoholic drinks do you have per week____________ or per month__________?
Do you smoke?
YES
NO
Did you ever smoke?
YES
NO
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