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Medicare Wellness Visit Health Risk Assessment, Study notes of Public Health

A questionnaire required for all First and Subsequent Annual Wellness Visits (AWV) and is used for Welcome to Medicare Visits (also called Medicare Initial Preventive Physical Exam or IPPE). The questionnaire includes questions about the patient's overall health, self-assessment of health, psychosocial health, health and habits, and screening and preventive services. The purpose of the questionnaire is to identify the patient's preventive care needs and possible health risks, and allow more time for discussion during the visit.

Typology: Study notes

2021/2022

Uploaded on 05/11/2023

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PLACE PATIENT LABEL HERE
UW Medicine
Harborview Medical Center University of Washington Medical Center
UW Medicine Primary Care Valley Medical Center UW Phys icians
MEDICARE WELLNESS VISIT HEALTH RISK ASSESSMENT
Page 1 of 6
UH3436 REV APR 22
Medicare Wellness Visit Health Risk Assessment
This questionnaire is required for all First and Subsequent Annual Wellness Visits (AWV) and is used for
Welcome to Medicare Visits (also called Medicare Initial Preventive Physical Exam or IPPE).
*If you have completed this questionnaire electronically through MyChart, please let the front
desk know*
TODAY’S DATE: / /
NAME: Last First MI BIRTHDATE: / /
Your answers to all the following questions will help the provider identify your preventive care needs and
possible health risks, and allow more time for discussion during the visit.
CARE PROVIDERS:
Please list care providers who are outside UW Medicine (including specialists, eye doctor, naturopaths,
etc.):
___________________________________________________________________________________
___________________________________________________________________________________
SELF ASSESSMENT OF HEALTH:
Please check one response for each question:
1) How do you rate your overall health the past 4 weeks? Excellent Good Fair Poor
2) Can you manage your overall health problems? Yes No
3) Because of any health problems, do you need the help of another person with your personal care
needs such as eating, bathing, dressing, or getting around the house? Yes No
4) Do you often get the emotional support you need? Always Usually Sometimes
Rarely Never
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PLACE PATIENT LABEL HERE

UW Medicine Harborview Medical Center – University of Washington Medical Center UW Medicine Primary Care – Valley Medical Center – UW Physicians MEDICARE WELLNESS VISIT HEALTH RISK ASSESSMENT Page 1 of 6

Medicare Wellness Visit Health Risk Assessment

This questionnaire is required for all First and Subsequent Annual Wellness Visits (AWV) and is used for Welcome to Medicare Visits (also called Medicare Initial Preventive Physical Exam or IPPE).

If you have completed this questionnaire electronically through MyChart, please let the front desk know

TODAY’S DATE: / /

NAME: Last First MI BIRTHDATE: / /

Your answers to all the following questions will help the provider identify your preventive care needs and possible health risks, and allow more time for discussion during the visit.

CARE PROVIDERS:

Please list care providers who are outside UW Medicine (including specialists, eye doctor, naturopaths, etc.):



SELF ASSESSMENT OF HEALTH:

Please check one response for each question:

  1. How do you rate your overall health the past 4 weeks?  Excellent  Good  Fair  Poor

  2. Can you manage your overall health problems?  Yes  No

  3. Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house?  Yes  No

  4. Do you often get the emotional support you need?  Always  Usually  Sometimes  Rarely  Never

PLACE PATIENT LABEL HERE

UW Medicine Harborview Medical Center – University of Washington Medical Center UW Medicine Primary Care – Valley Medical Center – UW Physicians MEDICARE WELLNESS VISIT HEALTH RISK ASSESSMENT Page 2 of 6

PSYCHOSOCIAL HEALTH:

Please check one response for each question:

In the past 2 weeks, how often have you been bothered by the following:

  1. Feelings that caused you distress or interfered with your ability to get along socially with family or friends?

Not at all Several days

More than half the days

Nearly every day

  1. Feeling stress over health, finances, relationships or work?

Not at all Several days

More than half the days

Nearly every day

  1. Body pain? Not at all Several days

More than half the days

Nearly every day

  1. Fatigue? Not at all Several days

More than half the days

Nearly every day

HEALTH AND HABITS:

Unless otherwise noted, please check one response for each question:

  1. In the past 7 days, how many days did you exercise?  0  1  2  3  4  5  6  7

  2. On days when you exercised, for how long did you exercise (in minutes)?  ________minutes (please provide estimate of minutes, 0-120+)  Does not apply

  3. How intense was your typical exercise?  Light (like stretching or slow walking)  Moderate (like a brisk walk)  Heavy (like jogging or swimming)  Very heavy (like fast running or stair climbing)  I am currently not exercising

  4. In the past 7 days, how often did you eat 3 or more servings of fruits and vegetables in a day?

 Not at all  Several days  More than half the days  Nearly every day

  1. In the past 7 days, how often did you eat 3 or more servings of high fiber or whole grain foods in a day?  Not at all  Several days  More than half the days  Nearly every day

  2. How would you describe the condition of your mouth and teeth, including false teeth or dentures?  Excellent  Very Good  Good  Fair  Poor

PLACE PATIENT LABEL HERE

UW Medicine Harborview Medical Center – University of Washington Medical Center UW Medicine Primary Care – Valley Medical Center – UW Physicians MEDICARE WELLNESS VISIT HEALTH RISK ASSESSMENT Page 4 of 6

  1. Is there anything in your home that might make you trip or slip, and fall?  Yes  No

  2. Do you ever leak urine or stool?  Yes  No

  3. Do you wear a liner, pad, or special underwear because of leakage?  Yes  No

In your present state of health, how much difficulty do you have with the following activities?

  1. Shopping  I can do this by myself

 I need some help to do it

 I cannot do this; another person needs to do it for me

  1. Using the telephone  I can do this by myself

 I need some help to do it

 I cannot do this; another person needs to do it for me

  1. Housekeeping  I can do this by myself

 I need some help to do it

 I cannot do this; another person needs to do it for me

  1. Laundry  I can do this by myself

 I need some help to do it

 I cannot do this; another person needs to do it for me

  1. Driving or using transportation  I can do this by myself

 I need some help to do it

 I cannot do this; another person needs to do it for me

  1. Managing your own finances  I can do this by myself

 I need some help to do it

 I cannot do this; another person needs to do it for me

  1. Taking your own medications  I can do this by myself

 I need some help to do it

 I cannot do this; another person needs to do it for me

SIGNS OF MEMORY ISSUES

Please check one response for each question:

  1. Have you experienced any memory issues or problems with thinking?  Yes  No

  2. Have any concerns about your memory been raised by family members, friends, caretakers, or others?  Yes  No

PLACE PATIENT LABEL HERE

UW Medicine Harborview Medical Center – University of Washington Medical Center UW Medicine Primary Care – Valley Medical Center – UW Physicians MEDICARE WELLNESS VISIT HEALTH RISK ASSESSMENT Page 5 of 6

SCREENING AND PREVENTIVE SERVICES

Your provider will review with you which of these screening and prevention measures are specifically recommended for you. Our records show which of these have previously been done within UW Medicine. Please answer this section if you have had any of the following screening or preventive measures done outside of UW Medicine most recently :

Screening / Test Please let us know where and when this was most recently done, IF it was last done outside of UW Medicine: Pneumococcal vaccines (e.g. Prevnar, Pneumovax)

Where completed:_____________________________ When completed:______________________________

Influenza Vaccine Where completed:_____________________________ When completed:______________________________

Hepatitis B Vaccine Where completed:_____________________________ When completed:______________________________ Mammogram Screening (Women) Where completed:_____________________________ When completed:______________________________ Results normal?  Yes  No  Unsure Pap Smear (Women ) Where completed:_____________________________ When completed:______________________________ Results normal?  Yes  No  Unsure Colorectal Cancer Screening Where completed:_____________________________ When completed:______________________________ Results normal?  Yes  No  Unsure Diabetes screening (e.g. glucose or blood sugar testing)

Where completed:_____________________________ When completed:______________________________ Results normal?  Yes  No  Unsure Cholesterol panel Where completed:_____________________________ When completed:______________________________ Results normal?  Yes  No  Unsure Bone Density Screening Where completed:_____________________________ When completed:______________________________ Results normal?  Yes  No  Unsure Eye exam Where completed:_____________________________ When completed:______________________________ Results normal?  Yes  No  Unsure