Medicare Wellness Exam Question Title * 1. Name Question Title * 2. Date of Birth Date Date Question Title * 3. How old are you? 65-69 70-79 80 or older Question Title * 4. Are you male or female? Male Female Question Title * 5. What is your race? White Black or African American Hispanic or Latino origin or descent Asian Native Hawaiian or other Pacific Islander American Indian or Alaskan Native Other Question Title * 6. During the past four weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad or downhearted and blue? Not at all Slightly Moderately Quite a bit Extremely Question Title * 7. During the past four weeks, has your physical and emotional health limited your social activities with family friends, neighbors, or groups? Not at all Slightly Moderately Quite a bit Extremely Question Title * 8. During the past four weeks, how much bodily pains have you generally had? No pain Very mild pain Moderate pain Severe pain Question Title * 9. During the past four weeks, was someone available to help you if you needed and wanted help? (For example, if you felt very nervous, lonely, or blue; got sick and had to stay in bed; needed someone to talk to; needed help with daily chores; or needed help just taking care of you.) Yes, as much as I wanted Yes, quite a bit Yes, some Yes, a little No, not at all Question Title * 10. During the past four weeks, what was the hardest physical activity you could do for at least 2 minutes? Very heavy Heavy Moderate Light Very light Question Title * 11. Can you get to places out of walking distance without help? (For example, can you travel alone on buses or taxis, or drive your own car? Yes No Question Title * 12. Can you do your housework without help? Yes No Question Title * 13. Because of any health problems, do you need anyone’s help with your basic needs such as eating, bathing, dressing or getting around the house? Yes No Question Title * 14. Can you handle your own money without help? Yes No Question Title * 15. During the past four weeks, how would you rate your health in general? Excellent Very good Good Fair Poor Question Title * 16. How have things been going for you during the past four weeks? Very well; could hardly be better Pretty well Good and bad parts about equal Pretty bad Very bad; could hardly be worse Question Title * 17. Are you having difficulties driving your car? Yes, often Sometimes No Not applicable, I do not use a car Question Title * 18. Do you exercise for about 20 minutes three or more days a week? Yes, most of the time Yes, some of the time No, I usually don’t exercise Question Title * 19. How often during the past four weeks have you been bothered by any of the following problems: Falling or dizzy when standing up? Never Seldom Sometimes Often Always Question Title * 20. Sexual problems? Never Seldom Sometimes Often Always Question Title * 21. Trouble eating well? Never Seldom Sometimes Often Always Question Title * 22. Teeth or denture issues? Never Seldom Sometimes Often Always Question Title * 23. Problems using the telephone? Never Seldom Sometimes Often Always Question Title * 24. Tiredness or fatigue? Never Seldom Sometimes Often Always Question Title * 25. During the past four weeks, how many drinks of wine, beer, or other alcoholic beverages did you have? 10 or more drinks per week 6-9 drinks per week 2-5 drinks per week One drink or less per week No alcohol at all Question Title * 26. Have you been given any information to help you with the following: Hazards in your house that might hurt you? Yes No Question Title * 27. Keeping track of medications? Yes No Question Title * 28. How often do you have trouble taking medicines the way you have been told to do? I don’t have to take medicine I always take them as prescribed Sometimes I take them as prescribed I seldom take them as prescribed Question Title * 29. How confident are you that you can control and manage most of your health problems? Very confident Somewhat confident Not very confident I don’t have any health problems Question Title * 30. Have you ever used tobacco? No Yes Unknown Question Title * 31. Cigarettes: How many years? Question Title * 32. Cigarettes: Age started? Question Title * 33. Cigarettes: Age stopped? Question Title * 34. Cigarettes: How many per day? Question Title * 35. Cigarillo: How many years? Question Title * 36. Cigarillo: Age started? Question Title * 37. Cigarillo: Age stopped? Question Title * 38. Cigarillo: How many per day? Question Title * 39. Cigar: How many years? Question Title * 40. Cigar: Age started? Question Title * 41. Cigar: Age stopped? Question Title * 42. Cigar: How many per day? Question Title * 43. Pipe: How many years? Question Title * 44. Pipe: Age started? Question Title * 45. Pipe: Age stopped? Question Title * 46. Pipe: How many per day? Question Title * 47. Chewing: How many years? Question Title * 48. Chewing: Age started? Question Title * 49. Chewing: Age stopped? Question Title * 50. Chewing: How many per day? Question Title * 51. Smokeless: How many years? Question Title * 52. Smokeless: Age started? Question Title * 53. Smokeless: Age stopped? Question Title * 54. Smokeless: How many per day? Question Title * 55. Snuff: How many years? Question Title * 56. Snuff: Age started? Question Title * 57. Snuff: Age stopped? Question Title * 58. Snuff: How many per day? Question Title * 59. Do you have smoke detectors in your home? Yes No Question Title * 60. Do you have firearms in your home? Yes No Question Title * 61. Do you use seatbelts when in a vehicle? Yes No Question Title * 62. Do you have carbon monoxide detectors in your home? Yes No Question Title * 63. Do you have radon in your home? Yes No Question Title * 64. If yes, treated or untreated? Treated Untreated Question Title * 65. What type of ambulatory device do you use: None Cane Manual Wheelchair Power Wheelchair Walker Other Question Title * 66. Have you had any falls in the past year? Yes No Question Title * 67. If yes, how many? Question Title * 68. If yes, did your falls result in injury? Please describe Question Title * 69. Do you have adequate vision to complete daily activities? Yes No Question Title * 70. Is your judgement adequate to complete daily activities? Yes No Question Title * 71. Is your memory safe to complete daily activities? Yes No Question Title * 72. Are you able to express your needs and/or desires adequately? Yes No Question Title * 73. Which is your dominant hand? Right hand Left hand Question Title * 74. How independent is your grooming ability? Independent Need Assistance Dependent Unable to Assess Question Title * 75. How independent are you when it comes to feeding yourself? Independent Need Assistance Dependent Unable to Assess Question Title * 76. How independent is your bathing ability? Independent Need Assistance Dependent Unable to Assess Question Title * 77. Are you able to use the bathroom independently? Independent Need Assistance Dependent Unable to Assess Question Title * 78. How independent are you getting in and out of bed? Independent Need Assistance Dependent Unable to Assess Question Title * 79. How independent are you when walking in your home? Independent Need Assistance Dependent Unable to Assess Question Title * 80. Do you have weakness in your legs? If so, which leg? None Right Left Both Question Title * 81. Do you have weakness in your arms/hand? If so, which arm/hand? None Right Left Both Question Title * 82. How is the hearing in your right ear? Functional Difficulty with Noise Deaf Hearing Aid Question Title * 83. How is the hearing in your left ear? Functional Difficulty with Noise Deaf Hearing Aid Question Title * 84. How often do you: Feel little interest or pleasure in activities? Never Seldom Several Days More than Half the Time Always Question Title * 85. Down, depressed or hopeless? Never Seldom Several Days More than Half the Time Always Question Title * 86. Have trouble falling or staying asleep? Never Seldom Several Days More than Half the Time Always Question Title * 87. Do you feel tired or have little energy? Never Seldom Several Days More than Half the Time Always Question Title * 88. Have a poor appetite or overeat? Never Seldom Several Days More than Half the Time Always Question Title * 89. Feel that you are a failure or have let yourself and others down? Never Seldom Several Days More than Half the Time Always Question Title * 90. Have trouble concentrating on activities? Never Seldom Several Days More than Half the Time Always Question Title * 91. Move or speak very slowly to a point that it is noticeable to others? Never Seldom Several Days More than Half the Time Always Question Title * 92. Feel that you would be better off dead or hurt yourself? Never Seldom Several Days More than Half the Time Always Question Title * 93. If you checked off any of the above problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Done
