Medicare Wellness Checkup Form

Ahead of the yearly visit, patients answer questions on mood, bladder control, falls, smoking, drinking, exercise and advance care planning. The care team walks in with a clear picture and can set up the patient portal too.

Use this template

In the Claude connectors directory

Page 1

Full name

First Name

Last Name

Visit date

Are you male?

Yes No

General health and safety

Over the last four weeks, how would you rate your general health?

Have you fallen two or more times in the past year?

Yes No

Are you afraid of falling?

Yes No

Do you lose your balance or feel dizzy or unsteady?

Yes No

Do you smoke?

Yes No

Are you ready to quit smoking?

Yes No Not applicable

Have you completed a medical power of attorney?

Yes No

Have you completed an advance directive?

Yes No

Are you worried that others are taking advantage of you?

Yes No

Are you worried that others are taking advantage of you financially?

Yes No

Over the last four weeks, how many alcoholic drinks did you have?

Do you exercise for about 20 minutes on three or more days a week?

Yes No

Page 2

Have there been any changes to your medications?

Yes No

Describe the medication changes

Do you have access to your patient portal account?

Yes No Not sure

Email to set up your patient portal account (leave blank if you have none)

Signature

Sign here

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