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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 1 COA/SDOH
1. Employment Status
*
Employed
Retired
Medically unable to work
Unemployed
2. Within the past 12 months did you worry that your food would run out before you got money to buy more?
*
Yes
No
3. Within the past 12 months, did the food you bought just not last and you didn't have money to get more?
*
Yes
No
4. In the last 4 weeks, how often did you have trouble paying for medication?
*
Never
Occasionally
Sometimes
Often
All the time
5. Do you have housing?
*
Yes
No
6. Are you worried about losing your housing?
*
Yes
No
7. 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
8. Do you feel physically and emotionally safe where you currently live?
*
Yes
No
9. Within the past 12 months, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
*
Yes
No
10. Within the past 12 months, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?
*
Yes
No
11. During the past 4 weeks, how much bodily pain have you had?
*
No pain
Very mild pain
Mild pain
Moderate pain
Severe pain
12. 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
13. 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
14. Do you use an assistive device for walking?
*
Yes
No
14a. If Yes - What type of device do you use?
Cane
Walker
Wheel Chair
Other
14b. If Yes - How often do you use your assistive device
All the time
Quite often
Sometimes
Rarely
Never
15. Do you have a hearing impairment that requires special equipment?
*
Yes
No
16. Do you have difficulty seeing and recognizing an object at arm's length or difficulty reading?
*
Yes
No
17. Do you have difficulty starting and focusing on maintaining a conversation?
*
Yes
No
18. 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
19. Do you struggle with transportation, shopping, grooming or bathing, preparing meals and housework, eating without help, or getting around your home?
*
No
Yes
19b. If yes, please select all that apply:
*
Transportation
Shopping
Grooming or bathing
Preparing meals
Housework
Eating without help
Getting around your home
Other
20. 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
21. Are you having difficulties driving your car?
*
Yes, often
Sometimes
No, never
Don't drive a car
22. 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
22b. If yes, please select all that apply:
*
Sexual problems
Trouble eating well
Teeth or dentures
Using telephone
Tired or fatigue
Other
Back
Next
Section 2: HOS
23. 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
24. Have you fallen 2 or more times in the past 12 months?
*
Yes
No
25. Are you afraid of falling.
*
Yes
No
26. Do you have any bladder control or issue with urine leakage?
*
Yes
No
Back
Next
Section 3: Wellness
27. During the past 4 weeks, how would you rate your health in general?
*
Excellent
Very good
Good
Fair
Poor
28. Have you been to the emergency room 2 or more times in the last 12 months?
*
Yes
No
29. Have you been admitted to the hospital in the last 12 months?
*
Yes
No
30. 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
31. Do you have any Advanced Directives?
*
Yes
No
31a. If Yes, what do you have in place.
Living Will
Actionable medical order/Do Not Resuscitate
Designated Healthcare surrogate or proxy
32. Have you ever had a stroke?
*
Yes
No
32a. 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
33. Do you have a joint replacement?
*
Yes
No
33a. If Yes - Which joint(s) have been replaced?
Knee
Hip
Other
33b. If Yes - Do you have any pain in the replaced joint?
Yes
No
34. Have you ever been diagnosed with COPD (Chronic Obstructive Pulmonary Disease)?
*
Yes
No
34a. 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
35. Are you on oxygen therapy?
*
Yes
No
36. Do you have an amputated limb?
*
Yes
No
36a. 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
37. Have you been diagnosed with diabetes?
*
Yes
No
37a. 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
37b. 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
37c. If Yes - Are you on medication to control your cholesterol?
Yes
No
37d. If Yes - Do you have numbness or tingling in your lower limbs or feet?
Yes
No
Submit
Should be Empty: