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Annual Wellness Questionnaire
Personal Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Email
*
example@example.com
Section 1A SDOH
1. Within the past 12 months did you worry that your food would run out before you got money to buy more?
*
Yes
No
2. Within the past 12 months, did the food you bought just not last and you didn't have money to get more?
*
Yes
No
3. Within the past 12 months have you ever stayed outside in a car, in a tent, in an overnight shelter, or temporarily inside someone else's home (i.e. couch surfing)?
*
Yes
No
4. Are you worried about losing your housing?
*
Yes
No
5. Within the past 12 months, have you or your family members you live with been unable to get utilities (heat, electricity) when it was really needed?
*
Yes
No
6. Within the past 12 months, has lack of transportation kept you from medical appointments, getting your medicines, non-medical meetings or appointments, work, or from getting things that you need?
*
Yes
No
7. Do you feel physically and emotionally safe where you currently live?
*
Yes
No
8. Within the past 12 months, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
*
Yes
No
9. Within the past 12 months, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?
*
Yes
No
Section 1B COA
1. Employment Status
*
Employed
Retired
Medically unable to work
Unemployed
2. In the last 4 weeks, how often did you have trouble paying for medication?
*
Never
Occasionally
Sometimes
Often
All the time
3. During the past 4 weeks, how much bodily pain have you had?
*
No pain
Very mild pain
Mild pain
Moderate pain
Severe pain
4. Where is the location of your pain?
Head
Shoulder(s)
Neck/Back
Arm(s)
Leg(s)
Knee(s)
Hip(s)
Hand(s)/Finger(s)
Other
5. On a scale of 0 to 10 (0 is no pain), how bad is your pain?
0
1
2
3
4
5
6
7
8
9
10
6. Do you use an assistive device for walking?
*
Yes
No
6a. If Yes - What type of device do you use?
Cane
Walker
Wheel Chair
Other
6b. If Yes - How often do you use your assistive device
All the time
Quite often
Sometimes
Rarely
Never
7. Do you have a hearing impairment that requires special equipment?
*
Yes
No
8. Do you have difficulty seeing and recognizing an object at arm's length or difficulty reading?
*
Yes
No
9. Do you have difficulty starting and focusing on maintaining a conversation?
*
Yes
No
10. In the past 4 weeks, how often did you have trouble thinking, remembering, or making decisions?
*
Not at all
Rarely
Sometimes
Often
Most of the time
11. Do you struggle with transportation, shopping, grooming or bathing, preparing meals and housework, eating without help, or getting around your home?
*
No
Yes
11b. If yes, please select all that apply:
*
Transportation
Shopping
Grooming or bathing
Preparing meals
Housework
Eating without help
Getting around your home
Other
12. Are you having difficulties driving your car?
*
Yes, often
Sometimes
No, never
Don't drive a car
13. In the past 4 weeks have you had trouble with: sexual problems, eating well, teeth or dentures, using the telephone, tired or fatigued?
*
No
Yes
13b. If yes, please select all that apply:
*
Sexual problems
Trouble eating well
Teeth or dentures
Using telephone
Tired or fatigue
Other
Section 2: HOS
1. Do you exercise for about 20 minutes 3 or more times a week?
*
Yes, most of the time
Yes, some of the time
No, I don't usually exercise this much
2. Have you fallen 2 or more times in the past 12 months?
*
Yes
No
3. Are you afraid of falling.
*
Yes
No
4. Do you have any bladder control or issue with urine leakage?
*
Yes
No
Back
Next
Section 3: Wellness
1. During the past 4 weeks, how would you rate your health in general?
*
Excellent
Very good
Good
Fair
Poor
2. Have you been to the emergency room 2 or more times in the last 12 months?
*
Yes
No
3. Have you been admitted to the hospital in the last 12 months?
*
Yes
No
4. How often do you have trouble taking medicine the way you have been told to take your medicine.
*
I don't take medicine
I always take my medicine as prescribed
I sometimes take my medicine as prescribed
I seldom take my medicine as prescribed
5. Do you have any Advanced Directives?
*
Yes
No
5a. If Yes, what do you have in place.
Living Will
Actionable medical order/Do Not Resuscitate
Designated Healthcare surrogate or proxy
6. Have you ever had a stroke?
*
Yes
No
6a. If Yes - Do you have any residual side effects?
Face impairment
Arm or limb weakness or numbness
Visual difficulties
Speech impairment or slurring
None
Other
7. Do you have a joint replacement?
*
Yes
No
7a. If Yes - Which joint(s) have been replaced?
Knee
Hip
Other
7b. If Yes - Do you have any pain in the replaced joint?
Yes
No
8. Have you ever been diagnosed with COPD (Chronic Obstructive Pulmonary Disease)?
*
Yes
No
8a. If Yes - When was your last breathing test (Spirometry)?
Within the last year
Over a year ago
I don't know
I have never had this test
9. Are you on oxygen therapy?
*
Yes
No
10. Do you have an amputated limb?
*
Yes
No
10a. If Yes - Do you have numbness or tingling at the site of your amputation or do you feel like your limb is still there?
Yes
No
11. Have you been diagnosed with diabetes?
*
Yes
No
11a. If Yes - When was your last dilated eye exam?
Within the last year
Over a year ago
I don't know
I have never had this exam
11b. If Yes - When were your feet last examined?
Within the last year
Over a year ago
I don't know
I have never had this exam
11c. If Yes - Are you on medication to control your cholesterol?
Yes
No
11d. If Yes - Do you have numbness or tingling in your lower limbs or feet?
Yes
No
Submit
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