8. Additional Wellness Questionnaire
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
My appointment is with:
*
Please Select
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, DO
David Verbofsky, MD
Diana Zackey, MD
Sarah Burbee
Appointment date:
*
-
Month
-
Day
Year
Date
Falls Risk
Pain Screening
ADLs
Other health issues
Urinary Incontinence
Medication Issues
Social Determinants of Health
Social Determinants of Health Score:
*
PHQ-9
PHQ-9 Score:
*
Audit C
Audit-C Score:
*
Flu Shot
Falls Risk
Have you fallen two or more times in the past year?
*
No
Yes
If yes, were you injured?
*
No
Yes
*
No
Yes
Do you have difficulty with dizziness or problems with balance?
Do you avoid doing things due to the fear of falling?
Do you have things in your house which might cause you to fall?
Physical Activity and Pain
*
Almost Never
Occasionally
Frequently
How often does physical or emotional health interfere with your daily activities?
How often do you take the escalator over the stairs?
How often does pain interfere with your normal activities?
On a scale of 0 to 10, (ten being strongest) how much pain do you have on a daily basis?
*
(No pain)
0
1
2
3
4
5
6
7
8
9
10
0 is (No pain), 10 is
If you do have daily pain, where is the pain located?
*
Approximately how many days each week are you physically active?
*
0 - 1 days
2 - 3 days
4 or more days
How many days a week do you exercise?
*
0 - 1 days
2 - 3 days
4 or more days
How many hours of sleep do you usually get each night?
*
5 or less hours
6 - 7 hours
8 or more hours
Activities of Daily Living
*
No
Yes
Do you need help eating, bathing, getting dressed, or getting around your home?
Do you need help preparing your own meals?
Do you need help doing your own housekeeping?
Do you need help with shopping?
Do you need help handling your own money?
Do you need help travelling by bus or taxi?
Do you need more help at home with your care or doing chores?
Do you drive a car?
*
No
Yes
If yes, do you have any difficulty driving?
*
No
Yes
When was your last dilated eye exam?
*
Other Health Issues
*
No
Yes
Do you have problems with your hearing?
Do you have problems with your memory?
Do you have trouble eating well?
Do you have trouble with your teeth or dentures?
Have you had a flu shot this year?
*
No
Yes
If not, do you want a flu shot?
*
No
Yes
Do you have a living will?
*
No
Yes
If yes, have you given us a copy?
*
No
Yes
Bladder Control
*
No
Yes
Is leaking of urine a problem for you?
Has urine leakage changed your activities or interfered with your sleep?
If urine leakage is a problem for you, would you be willing to try any of the following?
*
No
Yes
Medications
Bladder training exercises
Surgery
Medications
How often did you miss taking one or more of your medications in the last 2 weeks?
*
Never
Almost never
Occasionally
Frequently
I do not take any medication
*
No
Yes
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/questions about your medication side effects?
Do you have difficulty taking medicine the way you are instructed?
Other Issues Affecting Your Health
*
No
Yes
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?
*
Always
Usually
Sometimes
Never
How confident are you that you can control and manage most of your health problems?
*
Very
Somewhat
Not very confident
Not applicable
In the past 12 months, how often did you get an appointment in the amount of time you felt was appropriate?
*
Always
Usually
Sometimes
Never
In the past 12 months, how satisfied are you with the care or treatment you received in this office?
*
Very
Somewhat
Not very satisfied
Not applicable
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
Alcohol Screening
Did you have a drink containing alcohol in the past year?
*
Yes
No
How often did you have a drink containing alcohol in the past year?
*
Never
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?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
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