Date of Exam ________________
___________________Physician
Medicare Health Risk Assessment Form for Wellness Exam
For Medicare to pay for a wellness visit, patients must complete a
Health Risk Assessment in its entirety
Patient name: ________________________________________ Date of birth: ______________
Names of Physicians you currently see and date last seen:
Cardiology______________________
Pulmonary______________________
GI_____________________________
Rheumatology___________________
Neurology ______________________
Ophthalmology __________________
Dermatology ___________________
Urology _______________________
Orthopedics____________________
ENT__________________________
Gynecologist ___________________
Other _________________________
Current Medications
Medication
Dose & Directions
Why is this medication taken
Please include over the counter medications, vitamins and supplements.
Drug or Food Allergies: ______________________________________________________________
Have you had any overnight hospital stays in the past 12 months?
Yes No
If yes, why/where/when?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Have you fallen in the last year
In the past 7 days did you
need help from others for
any of the following?
Laundry and housekeeping
Banking or paying bills
Shopping
Using the telephone
Food preparation
Transportation
Do you drive a car
Taking your own medications
Wear a seatbelt
Using stairs
Wear sunscreen
Do you have stairs or throw
rugs in your home
Do have good lighting in your
house
Walking
Eating
Getting dressed
Please answer Yes or No to the
following:
Do you have problems with
your vision
Do you have problems with you
hearing or wear hearing aids
Do you have problems with
balance
Do you consume alcohol
Are you a smoker at this time
Have you been a smoker in the
past
If you are currently smoking,
would you like to quit smoking
How many servings of each per day?
Protein
Fruit/Vegetables
Whole Grains
Milk & Dairy
Supplemental Drinks
(Ensure)
Yes
No
Yes
No
Grooming
Bathing
Using the toilet
Vaccines
Influenza
Pneumonia
Zoster (shingle)
Tetanus
Do you have an Advanced Directive,
Living Will, or Power of Attorney?
Yes
No
If yes, please bring a copy with you to this
appointment.
Please mark any new, additional or worsening problems since your
last visit.
1. Constitutional
 Weight change
 Fever
 Decreased appetite
 Fatigue
 Skin problems
2. Eyes/Ears/Nose/Throat
 Change in vision
 Hearing loss
 Ringing in ears
 Nosebleeds
 Hoarseness
3. Respiratory
 Cough
 Shortness of breath
 Loud snoring
 Home oxygen
4. Cardiovascular
 Chest pain
 Irregular heartbeat
 Palpitations
 Ankle swelling
 Leg pain with walking
5. Gastrointestinal
 Difficulty swallowing
 Nausea or vomiting
 Heartburn/indigestion
 Abdominal pain
 Diarrhea
 Constipation
 Black or bloody stools
6. Urinary Tract
 Blood in urine
 Night time urination
 Frequent urination
 Discomfort on
urination
 Loss of bladder
control
7. Nervous system
 Severe headaches
 History of head injury
 Loss of
consciousness
 Double vision
 Dizziness
 Seizures
 Difficulty writing
 Difficulty speaking
8. Musculoskeletal
 Joint Pain
 Swollen joints
 Back pain
9. Blood
 Easy Bruising
 Swollen glands
10. Men only
 Penile sores or
discharge
 Testicular pain or
lumps
 Sexual function
concerns
11. Women only
 Vaginal
discharge/itching
 Lump in breasts
 Nipple discharge
 Monthly breast self
exams
Have any family members had any of the following?
If so, please list who:
Diabetes
Blood Disorders
Asthma
Migraines
Kidney Disease
Hepatitis
Cancer
Stomach Ulcers
Heart Disease
Thyroid Problems
High Blood Pressure
Stroke
Do you have additional problems or concerns?
________________________________________________________________________________
Patient Signature
Date
For Provider Use only:




Advanced Directives discussed
Medications reconciled
Preventative services reviewed
5-10 year plan given to patient
Additional comments:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Care Coordinator Signature
Date