Medicare Wellness Checkup Form
Please answer these questions before your Wellness Visit.
Name
First Name
Last Name
Visit date
 -
Month
 -
Day
Year
1
The Patient Health Questionnaire-2 (PHQ-2)
Over the past two weeks, how often have you been bothered by any of the following problems?
Rows
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things.
2
3
4
5
Feeling down, depressed or hopeless.
6
7
8
9
Overactive Bladder
The questions below ask about how bothered you may be by some bladder symptoms. Some people are bothered by bladder symptoms and may not realize that there are treatments available for their symptoms. Please select the choice that best describes how much you have been bothered by each symptom. Based on your responses, a score will be calculated.
How bothered have you been by the following problems?
Rows
Not at all
A little bit
Somewhat
Quite a bit
A great deal
A very great deal
Frequent urination during daytime hours.
10
11
12
13
14
15
An uncomfortable urge to urinate.
16
17
18
19
20
21
A sudden urge to urinate with little or no warning.
22
23
24
25
26
27
Accidental loss of small amounts of urine.
28
29
30
31
32
33
Nighttime urination.
34
35
36
37
38
39
Waking up at night because you had to urinate.
40
41
42
43
44
45
An uncontrollable urge to urinate.
46
47
48
49
50
51
Urine loss associated with a strong desire to urinate.
52
53
54
55
56
57
Are you male?
Yes
No
Bladder score
If your score is 8 or greater, you may have an overactive bladder. Talk to your doctor about getting urinalysis done. There are effective treatments for this condition.
During the past four weeks, how would you rate your health in general?
Excellent
Very good
Good
Fair
Poor
Have you fallen two or more times in the past year?
Yes
No
Are you afraid of falling?
Yes
No
Do you ever lose your balance or feel dizzy or unsteady?
Yes
No
Are you a smoker?
Yes
No
Are you ready to quit smoking?
Yes
No
Have you done your Medical Power of Attorney?
Yes
No
Have you done your Advance Directive?
Yes
No
Are you worried that others are taking advantage of you in general?
Yes
No
Are you worried that others are taking advantage of you financially?
Yes
No
During the past four weeks, how many drinks of wine, beer or other alcoholic beverages did you have?
10 or more drinks per week
6-9 drinks per week
2-5 drinks per week
One drink or less per week
No alcohol at all
Do you exercise for about 20 minutes three or more days a week?
Yes, most of the time
Yes, some of the time
No, I usually do not exercise this much
Back
Next
Clock Drawing Task
In the space below, please draw the face of a clock with hands and numbers. Indicate the time to be 11:10 (ten minutes after eleven).
Have there been any changes to your medications?
No
Yes
Please describe the medication changes.
If you are filling out more than one questionnaire, you only need to do this part once.
Do you have access to your Patient Portal account?
Yes
No
I don't know
Please provide your email address so we can set-up your Patient Portal account. If you don't have an email address, just leave the space blank.
example@example.com
Signature
Submit
Should be Empty: