Form 6281.109 - Medicare Annual Wellness Visit
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1
2Medicare Annual Wellness Visit
Name:
Date of Birth
Home Environment
Have you had any falls at home?
Yes
No
Number of stairs?_________ Throw rugs? Yes
No
Bath rails? Yes
No
Activities of Daily Living
Without assistance, are you able to:
Get out of bed? Yes No
Dress? Yes
No
Bathe?
Yes
No
Prepare meals? Yes No
Shop? Yes
No
Do you drive? Yes
No
Nutrition
Have you lost 10 lbs. or more in the past year? Yes
No
Current weight __________Current height___________
Social Support
Is there someone who would give you help if you were sick or disabled? Yes No
Who would help?______________________________________________
Who would be able to make health decisions for you if you were unable to make them
yourself? ____________________________________________________
Depression
Do you often feel sad or depressed?
Yes
No
If you answered yes, turn over and complete back page
Please list any other current physicians or suppliers involved in your medical care:
Name of physician(s)/supplier(s)
Reason:
1._____________________________________ ____________________________
2._____________________________________ ____________________________
3._____________________________________ ____________________________
4._____________________________________ ____________________________
5._____________________________________ ____________________________
6._____________________________________ ____________________________
7._____________________________________ ____________________________
Signature__________________________________
Date_____________
Provider Initials___________
6281.109
/kmt
(01/24/11)
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