Medicare Annual Wellness Visit Page 5

Name_____________________________________________________

Date______________

Nutritional Assessment

Score

Yes

I have an illness or condition that made me change

the kind and/or amount of food I eat.

I eat fewer than 2 meals per day

I eat few fruits or vegetables or milk products.

I have 3 or more drinks of beer, liquor or wine

almost every day.

I have tooth or mouth problems that make it hard

for me to eat.

I don’t always have enough money to buy the food

I need.

I eat alone most of the time.

I take 3 or more different prescribed or over-the-

counter drugs a day.

Without wanting to, I have lost or gained 10 pounds

in the last 6 months.

I am not always physically able to shop, cook

and/or feed myself.

0 votes

Parent category: Medical