Form 6281.109 - Medicare Annual Wellness Visit (Page 2 of 2) in pdf

Form 6281.109 - Medicare Annual Wellness Visit Page 2

Medicare Annual Wellness Visit

Patient

DOB:

Date

MEDICARE PHYSICAL

GERIATRIC DEPRESSION SCALE (short form)

Choose the best answer for how you felt over the past week.

{ Yes

{ No

1. Are you basically satisfied with your life?

{ Yes

{ No

2. Have you dropped many of your activities and interests?

{ Yes

{ No

3. Do you feel that your life is empty?

{ Yes

{ No

4. Do you often get bored?

{ Yes

{ No

5. Are you in good spirits most of the time?

{ Yes

{ No

6. Are you afraid that something bad is going to happen to you?

{ Yes

{ No

7. Do you feel happy most of the time?

{ Yes

{ No

8. Do you often feel helpless?

9. Do you prefer to stay at home, rather than going out and doing

{ Yes

{ No

new things?

{ Yes

{ No

10. Do you feel you have more problems with memory than most?

{ Yes

{ No

11. Do you think it is wonderful to be alive now?

{ Yes

{ No

12. Do you feel pretty worthless the way you are now?

{ Yes

{ No

13. Do you feel full of energy?

{ Yes

{ No

14. Do you feel that your situation is hopeless?

{ Yes

{ No

15. Do you think that most people are better off than you are?

SCORE

Provider Signature: _______________________________

Date:

6281.109

/kmt

(01/24/11)

Form 6281.109 - Medicare Annual Wellness Visit Page 2

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