AWV Questionnaire
Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
Date
Social History
What is your history of Alcohol Use? Alcohol Abuse: A pattern of drinking alcohol to excess that results in harm to one's health, interpersonal relationships, or ability to work. This includes binge drinking (men consuming more than 5 drinks and women consuming more than 4 drinks at one time Alcohol Dependency(Alcoholism): Physical and/or mental dependency on alcohol!that has specified symptoms including a high level of tolerance to the effects of alcohol as well as having withdrawal symptoms. Craving - a need or strong desire to drink alcohol Loss of Control - an inability to cease drinking, a feeling of no control of the situation. Physical Dependence - when not drinking, signs of withdrawal (nausea, sweating, and vomiting Tolerance - needs more alcohol to meet cravings and to get drunk.
Never Used Alcohol
Social Alcohol Use
Alcohol Abuse
Alcohol Dependency (Current)
Alcohol Dependency (Remission)
Other
Do you eat a healthy balanced diet with minimal salt and "bad fats"? Balanced Diet = Combination of fruits, vegetables, low fat dairy each day. Minimal Salt = Less than 1 Teaspoon Each Day. Bad Fats = fast food, fried food from a box or package
Yes
No
Have you had any unintentional weight loss over the past 6 months?
Yes
No
What is your current history of smoking cigarettes?
Current Smoker
Former Smoker
Never Smoked
If you answered that you are currently or were a former smoker in the previous question, how many years did you smoke for?
What is your history of illegal drug use?
No history of Illegal Drugs (Prescription or Street drugs)
Previous Illegal Drug Use (Prescription and/or Street Drugs) (Current or in Remisssion)
Self Assessment
Considering your age, how would you describe your overall health?
Excellent
Very Good
Good
Fair
Poor
How much difficulty, if any, do you have walking a 1/4 mile (about 2-3 blocks)
No Difficulty
A Little Difficulty
Some Difficulty
A Lot of Difficulty
Not Able to do it
In the past 7 days, how many days did you exercise?
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Have you been to the dentist in the past 12 months?
Yes
No
Mental Health Assessment
Over the past 2 weeks, have you felt down, depressed, or hopeless at any point?
Yes
No
Over the past two weeks, have you felt little to no pleasure in doing things?
Yes
No
Safety Assessment
Do you always fasten your seatbelt when you are in a car?
Yes
No
Do you have any problems with your hearing?
Yes
No
Have you been to an audiologist in the past 12 months?
Yes
No
Do you have any problems with balance?
Yes
No
Do you have any problems with walking?
Yes
No
A fall is when your body goes to the ground without being pushed. Have you fallen in the past 12 months?
Yes
No
If you answered yes to the previous question, how many times have you fallen over the past 12 months that you can remember?
Daily Activities Assessment
In the past 7 days, did you need help from others to perform everyday activities such as eating, getting dressed, grooming, bathing, walking, getting in and out of a bed or chair, or using the toilet?
Yes
No
In the past 7 days, did you need help from others to take care of things such as laundry and housekeeping, banking, shopping, using the telephone, food preparation, transportation or taking your own medication?
Yes
No
Review of Symptoms
General
Do you have increasing or worsening weakness or tiredness that is new to you in the last year?
Yes
No
What has been your HIGHEST pain this week?
No pain
1
2
3
4
5
6
7
8
9
Unbearable Pain
10
1 is No pain, 10 is Unbearable Pain
What has been your LOWEST pain this week?
Worst
1
2
3
4
5
6
7
8
9
Unbearable Pain
10
1 is Worst, 10 is Unbearable Pain
What has been your AVERAGE pain this week?
Worst
1
2
3
4
5
6
7
8
9
Unbearable Pain
10
1 is Worst, 10 is Unbearable Pain
What is your CURRENT pain?
Worst
1
2
3
4
5
6
7
8
9
Unbearable Pain
10
1 is Worst, 10 is Unbearable Pain
Vision
Have you had any recent changes to your vision?
Yes
No
Have you seen an ophthalmologist to have your eyes checked in the past 12 months?
Yes
No
Respiratory/Pulmonary
Have you recently had any trouble breathing?
Yes
No
Have you had a persistent cough that won't go away?
Yes
No
Cardiac (Heart)
Do you ever have chest pain, tightness, or heaviness in your chest?
Yes
No
Do you ever feel short of breath with daily activities such as dressing, showering/bathing, doing laundry, shopping, or walking?
Yes
No
Do you have difficulty breathing while lying down flat?
Yes
No
Do oyur legs swell?
Yes
No
Do you wake up at night feeling smothering, unable to breath or compression that causes you to sit upright?
Yes
No
Vascular (Arteries/Veins)
Do you have any numbness or tingling in your arms or legs?
Yes
No
When walking, do you have pain in the back of your legs (calves) that interferes with your lifestyle (Ex: Not able to exercises or walk?)
Yes
No
Do you have pain in the back of your legs that gets more severe when your legs are elevated and the pain diminishes when your legs are in a dependent position (Ex: Sitting on the bed with legs dangling over)
Yes
No
Musculoskeletal
Do you have increasing or worsening pain in your joints that is new to you within the past year? (Back, hips, knees, shoulders, or hands)
Yes
No
Bladder
Many people experience problems with urinary continence, the leakage of urine. In the past 6 months, have you accidentally leaked urine?
Yes
No
Other
Have you noticed any other symptoms that have become progressively worse over the past 12 months that you are concerned about?
Submit
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