ANNUAL WELLNESS VISIT / HEALTH RISK ASSESSMENT

Name: _________________________________________________________
(Full Name first, middle initial, last)

Date of Birth:
Widowed Hispanic/Latino Unknown

Marital status: Race/Ethnicity:

Single

Married

Partnered

Divorced

Separated

White/Caucasian Asian Hawaiian/Pacific Islander

Black/African American Other

Who Are Your Current Medical Providers?

Reason(s)/Indications (e.g., Outpatient Therapy, Dialysis, Specialist)

PERSONAL HEALTH HISTORY

Allergies to Medications Name the Drug Describe Reaction

Do you have other significant allergies? Medications Are you taking aspirin?

Yes / No (circle one) Describe: _____________________________________

Yes / No (circle one)

List your prescribed medications and over-the-counter drugs/medications, such as vitamins, supplements and inhalers.

Name the Drug

Strength

Frequency Taken

Do you have trouble affording your medications?

Yes / No (circle one) Yes / No (circle one)

Do you have any trouble taking your medications the way youve been told to take them by your physician?

______________________________________________ Patient Last Name, First Name List any medical problems/conditions diagnosed or treated Diagnosis/Problem Status
(Stable/Unstable)

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Comments
(How is condition treated: Medication? Therapy? etc.?)

Past Surgeries Type/Reason for Surgery Age at Time of Surgery or Year Comments / Complications / Concerns

Other Hospitalizations Reason for Hospitalization Age at Time or Year Comments / Complications / Concerns

Injuries Type of Injury Age at Time of Injury or Year Comments / Complications / Concerns

Preventive Care Annual Physical Colonoscopy Bone Density Date Pap Smear Mammogram Prostate test Date Cholesterol Level Dental Visit Other Date

Immunization Record Date Tetanus Td or Tdap Hepatitis A Pneumonia HPV (Gardasil) Hepatitis B Shingles (Zostavax) Date Influenza Other Date

______________________________________________ Patient Last Name, First Name

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FAMILY HEALTH HISTORY

Age
Father

Significant Health Problems

M F M F M F M F Grandmother
Maternal

Age

Significant Health Problems

Mother M F M F M Brothers/ Sisters F M F M F M F Adopted? Yes No Children

Grandfather
Maternal

Grandmother
Paternal

Grandfather
Paternal

HEALTH HABITS, PERSONAL SAFETY AND SOCIAL HISTORY

Alcohol Do you drink alcohol? Yes No If yes, what kind? Beer Wine Liquor/Spirits

How many drinks per week? Do you feel the need to cut down on drinking or do you feel guilty about drinking? Have close friends or relatives worried or complained about your drinking in the past year? How often in the past year have you had more than 4 (if a woman) or 5 (if a man) alcoholic drinks in a day? Daily Sex Are you sexually active? Do you have more than 1 partner? Are your partners Men Specify type: Are you concerned that you or your partner has been exposed to a sexually transmitted disease? Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness? Drugs Have you used marijuana in the last 12 months? Do you currently use recreational or street drugs? Have you ever given yourself street drugs with a needle? Tobacco Do you use or have you ever used tobacco? Cigarettes Packs/day Number of years Chew - times/day Year quit Pipe - times/day Yes Yes Yes Yes Yes Yes Cigars - times/day No No No No No No Women Both Yes No Often Sometimes Seldom Never Yes Yes No No Yes Yes No No

Do you currently use contraceptives?

______________________________________________ Patient Last Name, First Name

How would you rate your health? How well do you feel you take care of your health? How could you improve how you take care of yourself? Are you satisfied with your body size? Exercise Sedentary (No exercise) Mild exercise (i.e., climb stairs, walk 3 blocks, golf) Occasional vigorous exercise (i.e., work or recreation, less than 4 times/week for 30 min.) Regular vigorous exercise (i.e., work or recreation 4 times/week for 30 minutes) Diet Do you consider your eating habits: Are you on a special diet? Do you eat a healthy diet? (balance of fruits, vegetables, grains and protein) Number of meals you eat in an average day? How many cups of water do you drink daily? Do you have problems with chewing or swallowing? Caffeine Personal Safety None Coffee Tea Soda Good Fair Poor Excellent Excellent Very Good Very Good Good Good Fair Fair

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General

Poor Poor

Yes Yes

No No

Number of cups/cans per day? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No

Do you feel safe in your home? Do you have walking or balance problems? Have you fallen in the last two years? Does your home have rugs in hallways? Does your home have poor lighting? Do you have grab bars or handrails in bathrooms and stairways? Do you have vision or hearing loss? Do you wear seatbelts when driving or riding in a car? Is someone available to help you if you need or want help? Physical and/or mental abuse has also become a major public health issue. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?

Personal Hygiene / Activities of Daily Living

How many times a day do you brush your teeth? How often do you floss? Daily Often Sometimes Seldom Never Yes Yes Yes Yes No No No No

Do you have any problems feeding, dressing, or caring for yourself? Do you shop for yourself? Do you cook your own meals? Can you handle your own money without assistance? Who lives in your home? Do you have pets? Do you have any special interests or hobbies? Please specify: Occupation or prior occupation if retired: Primary language: Highest level of education: Middle School Masters Degree Are you satisfied with your reading and writing level? Very Satisfied Satisfied Neutral Dissatisfied High School Professional Degree Bachelors Degree Vocational Training

Yes

No

Very Dissatisfied

______________________________________________ Patient Last Name, First Name

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Personal Hygiene / Activities of Daily Living

Is your financial situation If yes, in what way?

Stable

Unstable Yes No

Do you feel your financial situation affects your health?

continued
Do you have an Advance Directive or Living Will? Yes No If you would like one, please ask your physician.

MENTAL HEALTH
Please rate your stress level: What do you mostly stress about? Do you have panic attacks? Do you feel depressed? Over the past 2 weeks, how often have you been bothered by the following problems? Feeling nervous, anxious or on edge Not being able to stop or control worrying Little interest or pleasure in doing things Feeling down, depressed or hopeless Do you have problems with eating or your appetite? Do you have trouble falling or staying asleep? Have you been bothered by feeling tired or having little energy? Have you ever attempted suicide, or do you seriously think about hurting yourself? Have you ever been to a counselor? Not at all Not at all Not at all Not at all Several days Several days Several days Several days More than half the days More than half the days More than half the days More than half the days Nearly every day Nearly every day Nearly every day Nearly every day Yes Yes Yes Yes Yes No No No No No Yes Yes No No High Moderate Low Yes No

CURRENT MEDICAL EQUIPMENT USED IN THE HOME Type of Equipment Purpose Current Supplier

______________________________________________ Patient Last Name, First Name

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CIRCLE Recent or Significant Symptoms

General Appetite change Enlarged lymph nodes Fatigue Hot flashes Night sweats Chills / Shaking Fevers Sleep problem Weight change Skin Bruises Change in mole Dryness Hair change Itching Rash Respiratory Breathing problems Blood in Sputum Cough Frequent respiratory infections Sputum Wheezing Snoring Shortness of breath Breathless when walking Breathless when flat in bed Head & Neck Vision changes Eye pain or problem Dental pain or problem Oral lesions Mouth pain or problem Dizziness / Vertigo Ear pain or problem Ringing in ears Headaches Hoarseness / Sore throat Neck or jaw pain Lumps in neck Sinus problems / Nose bleeds Seasonal allergies Sleep apnea Snoring Neurological ADD / ADHD Fainting Headaches / Migraines Memory problems Numbness / Tingling Tics / Tremors Seizures Speech problems L or R Handed (circle) Gastrointestinal Abdominal pain Bloating / Gas Blood in stools Black stools Change in stools Constipation Diarrhea Bowels irregular Hemorrhoids Laxative use Heartburn / Reflux Ulcers Nausea / Vomiting Swallowing problem Jaundice Genitourinary Incontinence / Leaking Urinary pain or problem Blood in urine Discharge Lump in testicle Menstrual trouble Menopause Pelvic pain Sexual pain or problem Cardiovascular Chest pain or pressure Palpitations Shortness of breath Ankle swelling Leg cramping Varicose veins Blood clots or phlebitis Cold feet or hands Fainting Musculoskeletal Joint pain or stiffness Joint swelling Muscle aches Leg pain / Cramps Back pain Weakness Restricted movement Numbness / Tingling Blood clots / Phlebitis Deformity / Amputation Breast Breast mass Change in size Nipple discharge Tenderness / Pain

Date Completed

_______________________ Completed by Staff

Completed by Patient

Reviewed by physician/provider Physician/Provider Signature Date