Medicare Annual Wellness Form - St. Luke Community Healthcare

Patient's Name: *

Phone Number *

Date of Birth: *

Primary Care Provider: *

Allergies: *

In general, how would you rate your health? *

How often do you get social/emotional support? *

How often do you take your medications as directed? *

How often do you use your seatbelt? *

Please check the activities you need help with: *

Do you have trouble controlling your bladder? *

Please select all that applies to you or your home: *

Entry ways are well lit

Sidewalks and entryways maintained

Carbon monoxide detector installed

Smoke detectors installed

Unidentified or expired medications are thrown out

What is your occupation? *

Who do you live with? *

Please select anything that applies to how your hearing affects your life: *

During the past 30 days, how often did you eat 5 servings of fruits and vegetables per day? *

How often you eat out per week? *

In the last 12 months, did you ever eat less than you thought you should because there wasn't enough money? *

Yes

No

I don't know

Your weight over the past year? * Your weight over the past year?

How many times per week do you exercise?

If you exercise, what is the duration?

If you exercise, what is the type?

Alcohol use? *

Yes

No

If yes, how many drinks per day?

Drug use? *

Yes

No

If yes, how much per day?

Patient/Guardian Name (this is your Electronic Consent): *

Date *

My Choice Advanced Directives (you may upload My Choice Advanced Directives form or print it out and bring with you):

Maximum file size: 67.11MB

POLST (you may upload POLST form or print it out and bring with you):

Maximum file size: 67.11MB

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Medicare Annual Wellness Visit Form