Medicare Wellness Questionnaire
Patient Name
*
Patient Date of Birth
*
/
Month
/
Day
Year
Are you having any problems with affording your medications?
Yes
No
Are you having any side effects from your medications?
Yes
No
Have you had an eye exam in the past year?
Yes
No
If yes, where?
Has the patient seen the dentist in the past 6 months?
Yes
No
Any limitation of bathing?
Yes
No
Any limitation dressing?
Yes
No
Any limitations with house work?
Yes
No
Any hearing difficulty/loss?
Yes
No
Any visual impairment?
Yes
No
On a scale of 0-5 (0 being pain free, 5 being severe pain), in the past 7 days how much did pain interfere with your day to day activities?
0
1
2
3
4
5
Pain Management
Is your gait normal?
Yes
No
Any urinary incontinence?
Yes
No
Have you fallen in the past 12 months?
Yes
No
If yes, then:
Once with no injury
Once with injury
2 or more times
In the past 12 months, have you sometimes felt unsteady when standing or walking?
Yes
No
In the past 12 months, have you worried about falling?
Yes
No
Do you find it difficult to interact with others or maintain an adequate social life?
Yes
No
Do you find it difficult to meet the daily needs of food, housing, or transportation?
Yes
No
Social Interaction
Daily Needs
Q
K
Submit
Should be Empty: