2. Wellness Questionnaire
Date of Birth
My appointment is with:
Allan Crimm, MD
Kenneth Barmach, MD
Lillian Cohn, MD
Zuleika Font, MD
Michelle Flynn, MD
Amanda Jankowski, CRNP
David Major, MD
Laura Oppenheim, MD
Kim Romansky, CRNP
Katherine Schmitz, MD
Mortimer Strong, MD
David Verbofsky, MD
Diana Zackey, MD
Social Determinants of Health
Social Determinants of Health Score:
How often did you miss taking one or more of your medications in the last 2 weeks?
I do not take any medication
Are you unsure or confused about what your medications are for?
Are you unsure or confused about how or when to take your medications?
Are you unsure or confused about why you need to take your medications?
Do you have any medications you cannot afford?
Do you have trouble getting your medications due to the inability to get to the pharmacy or have them delivered?
Do you have concerns or questions about your medication side effects?
Do you have difficulty taking medicine the way you are instructed?
Other Issues Affecting Your Health
In the past year, was there a time when you could not afford to see a doctor?
Are you worried at times you cannot get your medicine due to expenses?
Do you ever eat less because there is not enough food?
Are you worried that in the next few months you may not have housing?
Do you feel your safety is threatened in your home?
In the past year, have you had a hard time paying your utility bills?
Do you feel like it is a hardship to obtain household supplies?
Do you have any problems with access to transportation to get to your medical appointments?
Do you need a translator to communicate with your provider?
Do you have difficulty learning about your medical condition from the information given to you or what is told to you?
Do you miss having people around you?
Do you receive enough support from family and friends?
How confident are you that you can control and manage most of your health problems?
Not very confident
In the past 12 months, how often did you get an appointment in the amount of time you felt was appropriate?
In the past 12 months, how satisfied are you with the care or treatment you received in this office?
Not very satisfied
Depression Screening (PHQ-9)
In the last 2 weeks how often have you had:
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Little interest or pleasure than normal in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or feeling that you are a failure or that you have let yourself or family down
Trouble concentrating on things such as reading the newspaper or watching TV
Moving or speaking so slowly that other people could have noticed, or the opposite? (being so fidgety or restless that you have been moving around a lot more than usual)
Thoughts that you would be better off dead, or of hurting yourself in some way
Did you have a drink containing alcohol in the past year?
How often did you have a drink containing alcohol in the past year?
Monthly or less
2 - 4 times a month
2 - 3 times a week
4 or more times a week
How many drinks did you have on a typical day when you were drinking in the past year?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
How often did you have 6 or more drinks on one occasion in the past year?
Less than monthly
Daily or almost daily
Should be Empty: