Board Certified in Internal Medicine
Annual well visit questionnaire
1. What is your primary language spoken at home?
* 2. How do you prefer we communicate?
Phone: on record
* 3. In general, how would you describe your health?
* 4. What are your biggest concerns about managing your health? Check all that apply
I live in an unsafe environment [No]
Transportation to appointments [No]
Financial difficulty in paying for services/medicines [No]
I have difficulty taking my medicines [No]
Difficult reading or understanding instructions [No]
I am lonely or don’t have a lot of support at home [No]
I fall a lot at home [No]
* 5. How many times in the last 6 months have you been to the emergency room?
* 6. How many times in the last 6 months have you been admitted to the hospital? 0
* 7. Please list any new healthcare providers you have seen since your last visit with us.
Rest on record
* 8. Have you had any problems with your vision?
* 9. Have you had any problems with your hearing?
* 10. Do you or any of your friends or family members have any concerns about your memory? Yes
* 11. Please list any updates to your Family Medical History (family conditions that your doctor may not know about):
* 12. Do you use any tobacco products? (Cigarettes, chew, snuff, pipes, cigars)
* 13. If so, are you interested in quitting tobacco?
Yes (counseling was done today).
I don’t use tobacco [true]
* 14. How many times in the past year have you had 4 or more drinks in a day?
I don’t drink [true]
* 15. Which of the following can you do on your own without help?
Transfer in/out of chairs, etc. [yes]
Use the restroom [yes]
* 16. Does someone help you at home? If yes, please provide Caregiver name.
* 17. Many people experience leakage of urine, also called urinary incontinence. In the past 6 months, have you experienced leaking of urine?
* 18. Which of the following can you do on your own without help? Please check all that apply.
Shop for groceries [yes]
Drive/Use public transportation [yes]
Make meals [yes]
Use the telephone [yes]
Handle finances [yes]
Take Medications [yes]
* 19. Does your family or friends know what you want in an emergency situation or if you could not speak for yourself? Please check all that apply. (If you have any of the following, it would be helpful to have a copy provided to us for your medical record.) Yes, I have a living will
I have a power of attorney [yes] [No]
I have a MOLST
I have a POLST
I have completed 5 wishes
* 20. Would you like more information?
[yes] information/handout given
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