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Medicare Wellness Checkup Form -Form Fill
Q1
First Name
Q2
Last Name
Q3
Visit date
Q4
Over the past two weeks, how often have you been bothered by any of the following problems?
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed or hopeless.
Q5
How bothered have you been by the following problems?
Not at all
A little bit
Somewhat
Quite a bit
A great deal
A very great deal
Frequent urination during daytime hours.
An uncomfortable urge to urinate.
A sudden urge to urinate with little or no warning.
Accidental loss of small amounts of urine.
Nighttime urination.
Waking up at night because you had to urinate.
An uncontrollable urge to urinate.
Urine loss associated with a strong desire to urinate.
Q6
Are you male?
Yes
No
Q7
During the past four weeks, how would you rate your health in general?
Excellent
Very good
Good
Fair
Poor
Q8
Have you fallen two or more times in the past year?
Yes
No
Q9
Are you afraid of falling?
Yes
No
Q10
Do you ever lose your balance or feel dizzy or unsteady?
Yes
No
Q11
Are you a smoker?
Yes
No
Q12
Have you done your Medical Power of Attorney?
Yes
No
Q13
Have you done your Advance Directive?
Yes
No
Q14
Are you worried that others are taking advantage of you in general?
Yes
No
Q15
Are you worried that others are taking advantage of you financially?
Yes
No
Q16
During the past four weeks, how many drinks of wine, beer or other alcoholic beverages did you have?
10 or more drinks per week
6-9 drinks per week
2-5 drinks per week
One drink or less per week
No alcohol at all
Q17
Do you exercise for about 20 minutes three or more days a week?
Yes, most of the time
Yes, some of the time
No, I usually do not exercise this much
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