Medicare Annual Wellness Visit Page 2
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4Lalita Matta, MD | Estrela Chaves, NP, CDE
65 FREMONT STREET | MARLBOROUGH, MA 01752
P: 508-303-8553 | F: 508-303-0665
Name of Patient: _________________________________________________________________ DOB: _________________
Do you have any health concerns or NEW complaints you would like to address today?
Yes___ No___
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Past Medical/Surgical History:
(List illnesses, injuries, operations, hospitalizations, date and hospital)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Please list your current healthcare providers involved in your care and condition treated:
(Specialists, Therapists, VNA, etc.)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Are there any preventative tests you have done recently?
(Lab tests, Mammograms, X-rays, etc.)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you had any recent immunizations?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Do you have a health Care Proxy?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
General Health and Social/Emotional Support:
In general, would you say your health is:
Excellent___
Very Good___
Good___
Fair___
Poor___
Does handling such things as your health, finances, family or social relationships or work cause you stress? Yes___ No___
Do you get the social and emotional support you need?
Yes___ No___
Do you snore or has anyone told you that you snore?
Yes___ No___
Do you always fasten your seatbelt when you are in a car?
Yes___ No___
Social History:
Do you use tobacco?
Yes___ No___
Do you use alcohol?
Yes___ No___
Depression Screen:
Over the past 2 weeks, have you felt down, depressed or hopeless?
Yes___ No___
Over the past 2 weeks, have you felt little interest or pleasure in doing things?
Yes___ No___
Hearing Loss Screen:
Do you have trouble hearing the television or radio when others do not?
Yes___ No___
Do you have to strain or struggle to hear/understand conversations?
Yes___ No___
Rev. 01/26/2015
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