Medicare Annual Wellness Visit (Page 4 of 6) in pdf

Medicare Annual Wellness Visit Page 4

Name_____________________________________________________

Date______________

Please review the following tasks and check off the box that best applies to

you:

I can do on my own I need help I cannot do

Bathing

Eating

Dressing

Using the toilet

Getting out of or into bed or a chair

Manage medications

Use the Telephone

Arrange transportation

Prepare meals

Shopping

Perform Housework

Manage finances

Home Safety – Self-Assessment

Are all poisons (eg, medications, detergents, insecticides, cleaning

YES/NO

agents, polishes) kept out of reach of children and those with impaired

cognitive function and discarded when no longer needed?

Are working smoke alarm(s) and fire extinguisher(s) available for use?

YES/NO

Is there an escape plan in case of fire or other disaster?

YES/NO

Have throw rugs been removed or fastened down?

YES/NO

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

YES/NO

rugs/carpets or wrapped around nails?

Are non-slip mats in all bathtubs and showers?

YES/NO

Do all stairways have a railing or banister?

YES/NO

Are doorways, halls, and stairs free of clutter and adequately lit?

YES/NO

Are sidewalks and all outdoor steps clear of tools, toys, and other

YES/NO

articles?

Medicare Annual Wellness Visit Page 4