Medicare Annual Wellness Visit Page 3
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6Annual Wellness Visit Pre-Visit Questionnaire - Female
DIET
1. Do you eat fruit and/or vegetables every day?
Yes
No
2. Do you limit your salt intake?
Yes
No
3. Do you eat at least 3 dairy product servings daily or
Yes
No
take a calcium supplement?
4. Do you routinely eat fatty fish such as salmon or tuna or take a
vitamin D supplement containing at least 800 IUs of vitamin D per day?
Yes
No
PHYSICAL ACTIVITY
1. Do you usually exercise at least 30 minutes or more, 4 days a week?
Yes
No
HEPATITIS B RISK
1. Does anyone in your household have hepatitis B?
Yes
No
2. Do you currently use or have you ever used intravenous drugs?
Yes
No
3. Do you work in healthcare?
Yes
No
4. Do you require repeated blood or blood product transfusion?
Yes
No
5. Do you have liver disease?
Yes
No
6. Do you have diabetes?
Yes
No
7. Are you planning to spend more than 6 months, live in a rural area,
or have close physical or sexual contact with the local population
outside North America, Western Europe or Australia?
Yes
No
8. Have you had a hepatitis B vaccination?
Yes
No
HEPATITIS C RISK
1. Were you born between 1945 – 1965?
Yes
No
2. Have you had a blood transfusion before 1992?
Yes
No
3. Have you ever had a hepatitis C test?
Yes
No
STD SCREENING
1. In the past 12 months, have you had more than one sexual partner?
Yes
No
HIV TESTING
1. Have you ever had an HIV or AIDS test?
Yes
No
This form is a worksheet only, and will not become part of the legal medical record. All information from worksheet should be entered into EMR
electronically.
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