Medicare Annual Wellness Visit (Page 5 of 6) in pdf

Medicare Annual Wellness Visit Page 5

Annual Wellness Visit Pre-Visit Questionnaire - Female

FALLS RISK

1. Do you have difficulty moving in or out of beds or chairs?

Yes

2. Do you have difficulty with walking or balance?

Yes

1. Have you had 2 or more falls in the last 12 months?

Yes

HOME SAFETY

2. Have you completed a home safety evaluation?

Yes

GLAUCOMA SCREENING

1. Do you have a family history of glaucoma?

Yes

2. Are you over age 50 and of African-American descent?

Yes

3. Are you over age 65 and of Hispanic-American descent?

Yes

VISION

1. Have you had a general eye exam within the last 2 years?

Yes

HEARING IMPAIRMENT

1. Do you have difficulty with your hearing?

Yes

ABDOMINAL AORTIC ANEURYSM

1. Do you have a family history of abdominal aortic aneurysm?

Yes

2. Have you ever been screened for abdominal aortic aneurysm?

(usually done with an abdominal ultrasound)

Yes

DEPRESSION SCREENING

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Little interest or pleasure in doing things?

Not at all

Several days

More than half the days

Nearly every day

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.

Medicare Annual Wellness Visit Page 5