Annual Wellness Questionnaire
 
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First Name: *
Last Name: *
Date of Birth: *
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YYYY
Have you been admitted to the hospital in the last year?
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Have you had any surgeries or procedures since your last visit with us?
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What is your marital status? *
Are you sexually active? *
If yes, do you use protection?
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What is the highest grade or level of school you have completed? *
What is your employment status? *
What is your exercise level? *
How many times per week do you typically exercise?
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On days when you exercise, how many minutes on average do you exercise?
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What type of exercise activities do you typically do?
How many servings of fruits and/or vegetables do you typically eat? *
How many servings of high fiber and/or whole grain foods do you typically eat? *
How many servings of fried and/or high fatty foods do you typically eat? *
How many servings of high carb content do you typically eat (sweets, pasta, white bread, etc.)? *
Do you currently smoke cigarettes? *
Are you a former smoker? *
If yes, how long ago did you quit?
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Do you use other tobacco products? *
If yes, please specify:
If you are a current smoker, do you wish to quit?
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In a typical week, how many days do you drink alcohol? *
On days when you drink alcohol, how many drinks do you consume?
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In a typical week, how often do you drink more than 5 alcoholic beverages?
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If you currently drink alcohol, do you wish to quit?
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What is your level of caffeine consumption? *
Do you take a daily aspirin? *
How often is stress a problem for you? *
How well do you handle stress? *
Who do you live with? *
Do you feel safe at home? *
How often do you get the social and emotional support you need? *
Do you wear sunscreen when you go outdoors? *
Do you always fasten your seat belt when you are in the car? *
Do you ever drive after drinking or ride with a driver who has been drinking? *
Have you been diagnosed with COVID-19 in the last year? *
In general, how satisfied are you with your life? *
In general, how would you rate your physical health? *
How would you compare your physical health to last year? *
How would you rate your mental health? *
How would you compare your mental health to last year? *
Do you need help with dressing, eating, bathing, going to the bathroom, walking, or getting in or out of bed? *

Do you need help with preparing meals, transportation, shopping for groceries, managing your finances, performing light house work, making calls, or taking your medicine?                        

 *
Do you wear hearing aids? *
Do you find it difficult to follow a conversation in a noisy room or restaurant? *
Do you feel that people are mumbling or not speaking clearly? *
Do you experience ringing or noises in your ears? *
Do you hear better with one ear than the other? *
Do you feel handicapped by a hearing problem? *
Do you use any mobility aides? *
Required
Do you have any visual impairments? *
Have you fallen in the last year? *
If yes, how many times have you fallen?
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What caused you to fall?
Do you feel unsteady when standing or walking? *
Do you worry about falling? *
How many hours of sleep do you get each night? *
In the past six months, have you accidentally leaked urine? *
If yes, how much of a problem was this for you?
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Are you interested in discussing treatment options for urinary incontinence?
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Due to financial concerns, do you have to make choices between food, medication, heat, or any other necessity? *
If yes, what do you have to give up due to financial concerns?
Do you have an advance directive? 
(a legal document that explains how you want medical decisions to be made if you cannot make the decisions yourself)
 *
What is your code status in a medical emergency? *
If it was known that you would make a quick and full recovery, would you accept any of the following life sustaining treatment? Check all that apply. *
Required
If needed, would you want hospice/palliative care? *
Who could help you in case of an emergency? *
What is their relation to you? *
What is your emergency contact's phone number? *
Is there someone that will make medical decisions for you in the event that you cannot? *
If yes, what is the name of this person?
What is their relation to you?
Do you have a power of attorney?
(a person granted the authority to make financial decisions on your behalf if you are unable)
 *
Is a blood transfusion acceptable in an emergency? *
Are you an organ donor? *
Over the past 2 weeks, how often have you been bothered by the following problems?

0 = Not at all
1 = Several days
2 = More than half of the two weeks
3 = Nearly every day
 *
0 = Not at all
1 = Several days
2 = More than half of the two weeks
3 = Nearly every day
Little interest or pleasure in doing things
Feeling tired or having little energy?
Feeling down, depressed, or hopeless
Trouble falling asleep, staying asleep, or sleeping too much
Poor appetite or overeating
Feeling bad about yourself (like you're a failure or have let yourself or others down)
Trouble concentrating or focusing on things
Behavioral changes that you or anybody else has noticed
Thoughts that you would be better off dead or of hurting yourself
If you checked off any problems above,  how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *
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