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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:
How do you rate your overall health the past 4 weeks? Excellent Good Fair Poor
Can you manage your overall health problems? Yes No
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
Do you often get the emotional support you need? Always Usually Sometimes Rarely Never
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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:
- 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
- Feeling stress over health, finances, relationships or work?
Not at all Several days
More than half the days
Nearly every day
- Body pain? Not at all Several days
More than half the days
Nearly every day
- 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:
In the past 7 days, how many days did you exercise? 0 1 2 3 4 5 6 7
On days when you exercised, for how long did you exercise (in minutes)? ________minutes (please provide estimate of minutes, 0-120+) Does not apply
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
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
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
How would you describe the condition of your mouth and teeth, including false teeth or dentures? Excellent Very Good Good Fair Poor
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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
Is there anything in your home that might make you trip or slip, and fall? Yes No
Do you ever leak urine or stool? Yes No
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?
- 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
- 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
- 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
- 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
- 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
- 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
- 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:
Have you experienced any memory issues or problems with thinking? Yes No
Have any concerns about your memory been raised by family members, friends, caretakers, or others? Yes No
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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
