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Medicare Annual Wellness Visit Registration Form
St. Luke Community Healthcare Medicare Annual Wellness Visit Registration Form
*	Patient's Name
*	Date of Birth
	Exam Date
	Allergies
	Primary Care Provider
	Medications, Supplements, Vitimins: Please list all medications, supplements, or vitamins you take. You can bring your medication bottles to your visit as well.
	In general, how would you rate your health?	ExcellentVery GoodGoodFairPoor
	How often do you get social/emotional support?	All the timeMore than half the timeHalf the timeLess than half the timeRarelyNot at all
	How often to you take your medications as directed?	AlwaysSometimesSeldomI do not take any medications
	How often to you use your seat belt?	All the timeSome of the timeRarely or not at all
	Please select any activities that you need help with (check all that apply):	Eating Toileting Bathing Dressing Moving in and out of bed or a chair Using the phone Transportation Shopping Preparing Meals Housework Laundry Managing medications Managing finances No assistance needed
	Do you have trouble controlling your bladder?	Yes No
	Please select anything that applies to how your hearing affects your life:	No problems with hearing Embarrassed you when meeting new people Frustrates you when talking with family Have difficulty hearing when someone whispers Feel impaired by a hearing problem Hearing causes difficulty when visiting people Attending religious services less often because of hearing Argue with family because of hearing Difficulty hearing radio or TV Hearing limits or hampers personal or social life Difficulty hearing in a restaurant
	Please select all that applies to you or your home:	Entry ways are well lit Sidewalks and entryways maintained Carbon monoxide detector installed Smoke detectors installed Unidentified or expired medications are thrown out
	Have you fallen in the last year?	Yes No
	Do you feel unsteady when standing or walking?	Yes No
	Do you worry about falling?	Yes No
	Past personal illnesses, injuries, operations, or diagnosis: Please include dates and if you were hospitalized or not for each.
	Family Health History Particularly your parents or siblings (check all those that apply)	Alcoholism Liver Disease High Cholesterol Obesity Arthritis Diabetes High Blood Pressure Stroke Cancer Heart Disease Kidney Disease Thyroid Disease
	What is your occupation?
	Who do you live with?
	Days per week that you eat a well-balanced meal?
	What is your caffeine intake per day?
	Number of high-fat foods you have per day?
	Number of servings of fruits and vegetables you have per day?
	How often you eat out per week:
	How often you read food labels:
	Your weight over the past year:	StableDecreased >10lbsIncreased >lbsOther
	If other, explain:
	How many times do you exercise per week?
	If you exercise, what is the duration?
	If you exercise, what is the type?
	Tobacco Use:	Yes No
	If yes (smoke or chew) how many packs per day?
	Alcohol Use:	Yes No
	If yes, how many drinks per day?
	Drug Use:	Yes No
	If yes, describe:
	Current list of patient's providers/specialists/medical equipment suppliers: Include Name, Specialty, and Reason
	I consent to discuss end-of-life issues with my healthcare provider:	Yes No
	Patient/Guardian Name Electronic Consent
	Date
	My Choice Advanced Directives You can upload My Choice Advanced Directives to this form or you may print it out and bring it with you to your appointment.
	POLST You can upload the POLST form here or you may print it out and bring it with you to your appointment.