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Medicare Wellness Visit Patient Intake

Demographics

List any hospitalizations, major illness or visits to the emergency room since last year or visit. Please include date of visit, reason for visit, and the location of visit.

Changes in Medications or Allergies Since Last Year or Visit

Please include the medication name, dosage, and the reason.

Please include allergy name(s) and reactions.

Medical History




















Please include equipment name and who provides the equipment.

Please include the provider / specialist name and reason you see them.





















Please include name and date of operation(s).

Activities of Daily Living

















Accident Prevention










Health Screening: Substance Use, Diet, Exercise, Fall Risk


Please indicate time period of day or week.























Patient Health Questionnaire








































End of Life Decision Making