Medicare Annual Wellness Visit Page 4
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6Annual Wellness Visit Pre-Visit Questionnaire - Female
ALCOHOL & DRUG USE
1. How many times in the past year have you had 4 or more drinks in a day?
0
1
2
3
4
5
6+
2.
How many times in the past year have you used an illegal drug or used a prescription medication for non-
medical reasons? For example, because of the experience or feeling it caused.
0
1
2
3
4
5
6+
BOWEL/BLADDER CONTROL
1. Do you have difficulty controlling your urine or bowel movements?
Yes
No
ACTIVITIES OF DAILY LIVING
Do you need help with any of the following?
1. Bathing
Yes
No
2. Dressing
Yes
No
3. Using the toilet
Yes
No
4. Eating
Yes
No
INSTRUMENTAL ACTIVITIES OF DAILY LIVING
1. Can you travel alone by bus, taxi, or drive your own car?
Yes
No
2. Can you shop for groceries or clothes without help?
Yes
No
3. Can you prepare your own meals?
Yes
No
4. Can you handle your own money without help?
Yes
No
5. Do you have enough money to afford your medications,
groceries and day-to-day bills?
Yes
No
6. Can you do your own housework without help?
Yes
No
7. Are you being abused or neglected?
Yes
No
PSYCHOSOCIAL RISKS
1. Is there someone available to help you if you needed and wanted help?
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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