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New Questions 1

This document is a health risk assessment questionnaire that asks a patient questions about their general health, lifestyle habits, living situation, and any health issues or concerns. It covers topics like pain levels, exercise routine, diet, alcohol use, falls, home safety, memory, hearing, and need for assistance with daily activities. The questionnaire is used to evaluate a patient's health risks and needs.

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165 views2 pages

New Questions 1

This document is a health risk assessment questionnaire that asks a patient questions about their general health, lifestyle habits, living situation, and any health issues or concerns. It covers topics like pain levels, exercise routine, diet, alcohol use, falls, home safety, memory, hearing, and need for assistance with daily activities. The questionnaire is used to evaluate a patient's health risks and needs.

Uploaded by

Shobhit
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Health Risk Assessment Questionnaire

Office Use Only:  Medicare Wellness Visit  Welcome to Medicare Visit

Name: _____________________________ Date of Birth: ________________________________


In general, would you say your health is? Do you know where to locate and properly use a first aid kit
and fire extinguisher in case of an emergency?
 Excellent
 Good  Yes
 Fair  No
 Poor In the past 7 days, did you need help from others to perform
In general, how satisfied are you with your life? everyday activities such as eating, getting dressed, grooming,
bathing, walking, or using the toilet?
 Very satisfied
 Satisfied
 Yes

 Dissatisfied
 No
In the past 7 days, did you need help from others to take care
 Very Dissatisfied
of things such as laundry and housekeeping, banking,
In the past 7 days, how much pain have you felt? shopping, using the telephone, food preparation,
 None transportation, or taking your own medications?
 Some  Yes
 A lot  No
Do you usually exercise at least 30 minutes or more, 5 days a In the past 7 days have you had any problems staying or
week? falling asleep?
 Yes  Yes
 No  No
Do you usually eat a diet that has at least 4 servings of fruit & In the past 7 days have you had problems with constipation?
vegetables, includes whole grain & fiber and avoids other
than occasional servings of high fat foods?
 Yes
 No
 Yes
In the past year have you had:
 No
How would you describe the condition of your mouth and
 2 or more falls or a fall with an injury
teeth (including false teeth or dentures)?  No falls or 1 fall with no injury
Does your home have rugs in the hallway?
 Excellent
 Good  Yes
 Poor  No
In a typical week, how much alcohol do you drink? Does your home have grab bars in the bathroom?

 None  Yes
 One drink per day or less  No
 Two drinks per day Does your home have handrails on the stairs?
 More than 2 drinks per day  Yes
Do you ever have 5 or more alcoholic drinks on one occasion?  No
 Yes Does your home have good lighting?
 No  Yes
Do you always fasten your seat belt when you are in the car?  No
 Yes
 No
(GO TO NEXT PAGE)

HRA Template 1
Health Risk Assessment Questionnaire

Do you or any of your friends or family members have any


concerns about your memory?
 Yes
 No
Do you have any problems with your hearing?
 Yes
 No

HRA Template 2

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