Wellness Packet

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Today's Date(Required)

Month

Day

Year

Wellness Visit Form

Patient Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Phone(Required)

Gender(Required)

Employment Status(Required)

Age Group(Required)

Marital Status(Required)

Define "other"(Required)

Number of Children(Required)

Please enter a number from 0 to 15.

Race(Required)

Falls Assessment

Have you fallen in the past year?(Required)

Do you worry about falling?(Required)

Do you feel unsteady standing or walking?(Required)

Do you use a cane or walker?(Required)

Have you seen a physical therapist in the past year?(Required)

BLADDER CONTROL ASSESSMENT

Is bladder control a problem for you?(Required)

In the past 60 days, has urine leakage changed your daily activities?(Required)

In the past 60 days, has urine leakage interfered with your sleep?(Required)

If urine leakage is a problem for you, would you be willing to try one of the following?

Medications(Required)

Exercise(Required)

Surgery(Required)

PHYSICAL HEALTH

How often does physical health interfere with your daily activities?(Required)

How often do you choose to take the stairs over an elevator or escalator?(Required)

Approximately how many days each week are you physically active?(Required)

Are you as active as other people your age?(Required)

During the past 4 weeks, how much bodily pain have you generally had?(Required)

What is your pain level today on a scale from 1-10?(Required)

During the past 4 weeks, what was the hardest physical activity you could do for at least 2 minutes?(Required)

Can you get to places out of walking distance without help? (i.e. can you travel alone by bus, taxi, or drive your own car)?(Required)

Can you shop for groceries or clothes without help?(Required)

Can you prepare your own meals?(Required)

Can you do your own housework without help?(Required)

Can you handle your own money without help?(Required)

Do you need help with any of the following:(Required)

check all that apply

Eating

Bathing

Dressing

Getting around your home?

None of the above

Are you having difficulties driving your car?(Required)

Do you fasten your seat belt when you are in a car?(Required)

How often during the past 4 weeks have you been bothered by any of the following problems?

Fall or dizzy when standing up(Required)

Sexual problems(Required)

Trouble eating(Required)

Teeth or dentures(Required)

Using the phone(Required)

Are you a smoker?(Required)

Are you willing to quit?(Required)

During the past 4 weeks, how many drinks or wine, beer, or other alcoholic beverages have you had?(Required)

Have you been given any information about the following:

Hazards in your house that might hurt you?(Required)

Keeping track of your medication?(Required)

Emotional Health

How would you describe your emotional health?

In the last month, has your emotional health (feeling anxious or depressed) interfered with your daily activities?(Required)

How many hours of sleep do you typically get each night?(Required)

In the last month, have you accomplished less than you would like or been more careless at work or while performing daily activities?(Required)

Are you worried about your memory?(Required)

Colorectal Screening

Have you had a colorectal screening in the past 10 years?(Required)

If yes, when?(Required)

Female Screening

Have you had a mammogram in the last 2 years?(Required)

If yes, when?(Required)

Location of mammogram(Required)

Have you had a pap smear?(Required)

If yes, when?(Required)

Location and provider of pap smear(Required)

General Screening

Have you had an abnormal aortic aneurysm ultrasound?(Required)

If yes, when?(Required)

Have you had an eye exam in the last 2 years?(Required)

If yes, when?(Required)

If yes, where?(Required)

Are there any preventative tests you have done recently (i.e. mammograms/labs/x-rays)?(Required)

If yes, when?(Required)

If yes, where?(Required)

Directive for Health Care

Do you have a living will or advanced directive?(Required)

Would you like to upload it or bring in a copy?(Required)

File(Required)

Drop files here or

Max. file size: 128 MB.

Immunizations

Have you had any recent immunizations?(Required)

If yes, check all that apply(Required)

Pneumonia Vaccine

Shingles Vaccine

Flu Vaccine

Tdap

COVID

Hepatitis B Vaccine

Medications

Remembering to take your medication can sometimes be challenging. In the last 2 weeks, have you forgotten to take your medications?(Required)

Understanding how and when to take medication and knowing why it was prescribed is important. Do you have any questions on how and when to take your medication or why it was prescribed?(Required)

Some medications are difficult to afford, even with help from insurance. Do you have any medications that are unaffordable?(Required)

Every medication has side effects. Do you have any unanswered worries or questions related to your medications or side effects?(Required)

Review your medication list with your physician

List any medications that you currently take (including over the counter)

To add medications, select the plus sign to the right of the field.

Name of Medication

Strength

Direction

List any providers and their specialties

To add providers, select the plus sign to the right of the field.

Provider Name

Specialties