MEDICARE WELL EXAM HEALTH RISK ASSESSMENT FORM NAME: Date: AGE GENDER: MALE FEMALE RACE: CAUCASIAN AFRICAN/AFRICAN AMERICAN ASIAN HISPANIC HAWAIIAN/PACIFIC ISLANDER NATIVE ALASKAN/NATIVE AMERICAN OTHER (LIST) ETHNICITY: (IRISH, FRENCH, SAMOAN, EGYPTIAN, ETC) LIST HEALTH STATUS: HEALTHY FRAIL ACUTELY ILL CHRONICALLY ILL TERMINALLY ILL OTHER (LIST) PHYSICAL FUNCTIONING: ABLE TO WALK/RUN-PHYSICALLY FIT WALK ONLY WALK WITH ASSISTANCE, WALKER, CANE WHEELCHAIR MOTORIZED SCOOTER BED-RIDDEN PSYCHOSOCIAL RISKS: CHECK ALL OR ANY THAT APPLY MENTALLY WELL, NOT DEPRESSED DEPRESSION EXCESSIVE STRESS LONELY EXCESSIVE ANGER SOCIALLY ISOLATED CHRONIC PAIN CHRONIC FATIGUE NAME: DATE: Page 1
BEHAVIORAL RISKS TOBACCO USE: NEVER SMOKED SMOKED BUT QUIT CURRENT SMOKER CURRENT SMOKERS: NUMBER OF PACKS PER DAY HOW MANY YEARS FORMER SMOKERS: NUMBER OF PACKS PER DAY HOW MANY YEARS PHYSICAL ACTIVITY: EXERCISE NUMBER OF DAYS PER WEEK HOURS PER DAY VERY RARE EXERCISE, NOT ON A REGULAR BASIS SEDENTARY, ALMOST NO EXERCISE OR NONE NUTRITION: WELL NOURISHED OVER-WEIGHT POOR NUTRITION ORAL HEALTH GOOD AVERAGE POOR ALCOHOL CONSUMPTION NEVER DRINK ALCOHOL RARELY DRINK DRINK REGULARLY, NOT DAILY DAILY ALCOHOL USE FAVORITE OR REGULAR DRINK AVERAGE NUMBER OF DRINKS PER DAY (WHEN DRINKING) I DESCRIBE MYSELF AS A CURRENT OR FORMER ALCOHOLIC YES NO NAME: DATE: Page 2
SEXUAL ACTIVITY HETEROSEXUAL HOMOSEXUAL BI-SEXUAL OTHER (LIST) NO CURRENT SEXUAL ACTIVITY NUMBER OF CURRENT OR RECENT (5 YEARS) SEXUAL PARTNERS NO CONCERN FOR CURRENT SEXUALLY TRANSMITTED DISEASES I AM CONCERNED ABOUT CURRENT SEXUALLY TRANSMITTED DISEASES MOTOR VEHICLE SAFETY: WEAR SEAT BELT ALL OF THE TIME WEAR SEAT BELT SOMETIMES WEAR SEAT BELT NEVER HOME SAFETY: MY HOME IS SAFE I AM CONCERNED ABOUT MY HOME S SAFETY NUMBER OF FALLS AT HOME IN PAST YEAR ACTIVITIES OF DAILY LIVING: I CAN DRESS MYSELF WITHOUT ASSISTANCE I ALWAYS NEED HELP GETTING DRESSED I SOMETIMES NEED HELP GETTING DRESSED I CANNOT PARTICIPATE IN DRESSING MYSELF I CAN FEED MYSELF ALL OF THE TIME I ALWAYS NEED HELP WITH EATING I SOMETIMES NEED HELP WITH EATING FEEDING TUBE I CAN GO TO THE BATHROOM WITHOUT ASSISTANCE ALL OF THE TIME I NEED HELP GOING TO THE BATHROOM SOMETIMES I NEED HELP GOING TO THE BATHROOM ALL OF THE TIME NAME: DATE: Page 3
I CAN GROOM MYSELF ALL OF THE TIME (COMB HAIR, BRUSH TEETH, ETC) I NEED HELP WITH GROOMING I HAVE NO CONCERN ABOUT BALANCE OR FALLING I HAVE SOME CONCERN ABOUT BALANCE OR FALLING I AM WORRIED ABOUT BALANCE AND FALLING I AM ABLE TO TAKE A SHOWER OR BATH EVERY DAY WITHOUT ASSISTANCE I SOMETIMES NEED ASSISTANCE WITH BATHING OR SHOWERING I ALWAYS NEED ASSISTANCE WITH BATHING OR SHOWERING I RECEIVE ASSISTANCE WITH BED-BATH REGULARLY INSTRUMENTAL ACTIVITIES OF DAILY LIVING I AM ABLE TO SHOP WITHOUT ASSISTANCE I SOMETIMES NEED HELP WITH SHOPPING I ALWAYS NEED HELP WITH SHOPPING I CANNOT SHOP AND HAVE OTHERS DO IT FOR ME I AM ABLE TO PREPARE MY OWN MEALS AND FOOD SAFELY I NEED ASSISTANCE TO PREPARE MY MEALS AND FOOD ALL OF MY MEALS ARE PREPARED FOR ME NAME: DATE: Page 4
I AM ABLE TO USE THE TELEPHONE WITHOUT DIFFICULTY I CAN USE THE PHONE, BUT SOMETIMES I HAVE TROUBLE I CANNOT USE THE PHONE BY MYSELF I CAN DO ALL OF MY OWN HOUSEKEEPING I NEED HELP WITH MY HOUSEKEEPING I CANNOT DO MY HOUSEKEEPING, AND OTHERS DO IT FOR ME I CAN DO ALL OF MY OWN LAUNDRY I NEED ASSISTANCE SOMETIMES WITH MY LAUNDRY SOMEONE ELSE DOES MY LAUNDRY ALL OF THE TIME MODE OF TRANSPORTATION (CHECK ALL THAT APPLY) CAR, WITH ME OR SPOUSE/PARTNER DRIVING CAR, BUT I CANNOT DRIVE SAFELY BUS TAXI WALK MOTORCYCLE BIKE OTHER(LIST) RESPONSIBILITY FOR MEDICATION I AM ABLE TO TAKE MY OWN MEDICATION AND I KNOW WHAT MEDICATIONS I AM TAKING I TAKE MY OWN MEDICATIONS BUT I DO NOT KNOW WHAT MEDICATIONS I AM TAKING I NEED SOME ASSISTANCE WITH MEDICATIONS I NEED SOMEONE TO HELP ME TAKE MY MEDICATIONS ALL OF THE TIME _ I DO NOT TAKE ANY MEDICATION ON A REGULAR BASIS NAME: DATE: Page 5
RESPONSIBILITY FOR HOME FINANCES I AM ABLE TO TAKE CARE OF MY HOUSE FINANCES I NEED SOME ASSISTANCE WITH HOME FINANCES I NEED SOMEONE TO HELP ME ALL OF THE TIME WITH MY FINANCIAL ISSUES VACCINES I GET FLU SHOT EVERY YEAR, OR MOST YEARS I WANT FLU SHOT TODAY (SEPTEMBER THROUGH MARCH) I REFUSE FLU SHOT PNEUMONIA VACCINE: ALREADY HAVE RECEIVED WANT MORE INFORMATION REFUSE SHINGLES/ZOSTAVAX VACCINE: ALREADY HAVE RECEIVED WANT MORE INFORMATION REFUSE CODE STATUS: FULL CODE IF MY HEART STOPS OR I STOP BREATHING, I WANT MEDICAL PROFESSIONALS TO DO EVERYTHING TO BRING ME BACK. MAY INCLUDE BUT NOT LIMITED TO CHEST COMPRESSIONS, ELECTRIC SHOCK OF MY HEART, USE OF A VENTILATOR, FEEDING TUBE, ETC. CODE STATUS: DNR DO NOT RESUSCITATE IF MY HEART STOPS OR I STOP BREATHING, I WANT MEDICAL PROFESSIONALS TO HOLD MY HAND, MAKE ME COMFORTABLE, PROVIDE PAIN MEDICATION IF NECESSARY, AND PROVIDE OTHER COMFORT CARE AS NEEDED. I KNOW THAT IF MY HEART STOPS OR IF I STOP BREATHING, THAT I WILL LIKELY DIE DURING THIS EPISODE OF CARE. NAME: DATE: Page 6
CODE STATUS: WANT MORE INFORMATION I WANT MORE INFORMATION OR I WANT TO TALK MORE TODAY ABOUT CODE STATUS LIVING WILL: I HAVE A LIVING WILL I DO NOT HAVE A LIVING WILL MEDICAL POWER OF ATTORNEY I HAVE A MEDICAL POWER OF ATTORNEY. NAME I DO NOT HAVE A MEDICAL POWER OF ATTORNEY INTERNAL OFFICE USE: PATIENT REFUSES TO FILL OUT FORM PATIENT DID NOT COMPLETE FORM PATIENT NOT ABLE TO FILL OUT FORM NAME: DATE: Page 7