Medicare Wellness Exam

During the past four weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad, or downhearted and blue?
[select name="variable_1" value="Not    at    all|Slightly|Moderately|Quite    a    bit|Extremely"]

During the past four weeks, has your physical and emotional health limited your social activities with family, friends, neighbors, or groups?
[select name="variable_2" value="Not    at    all|Slightly|Moderately|Quite    a    bit|Extremely"]

During the past four weeks, how much bodily pain have you generally had? 
[select name="variable_3" value="No    pain|Very    mild    pain|Mild    pain|Moderate    pain|Severe    pain"]

During the past four weeks, was someone available to help you if you needed and wanted help? (For example, if you felt very nervous, lonely, or blue; got sick and had to stay in bed; needed someone to talk to; needed help with daily chores; or needed help just taking care of yourself.)
[select name="variable_4" value="Yes,    as    much    as    I    wanted|Yes,    quite    a    bit|Yes,    some|No,    not    at    all"]

During the past four weeks, what was the hardest physical activity you could do for at least two minutes?
[select name="variable_5" value="Very    heavy|Heavy|Moderate|Light|Very    Light"]

Can you get to places out of walking distance without help? (For example, can you travel alone on buses or taxis, or drive your own car?)
[select name="variable_6" value="Yes|No|N/A"]

Can you go shopping for groceries or clothes without someone’s help?  
[select name="variable_7" value="Yes|No|N/A"]

Can you prepare your own meals?  
[select name="variable_8" value="Yes|No|N/A"]

Can you do your housework without help?
[select name="variable_9" value="Yes|No|N/A"]

Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house?
[select name="variable_10" value="Yes|No|N/A"]

Can you handle your own money without help?
[select name="variable_11" value="Yes|No|N/A"]

During the past four weeks, how would you rate your health in general? 
[select name="variable_12" value="Excellent|Very    Good|Good|Fair|Poor"]

How have things been going for you during the past four weeks?
[select name="variable_13" value="Very well; could hardly be better.|Pretty well.|Good and bad parts about equal|Pretty bad.|Very bad; could hardly be worse."]

Are you having difficulties driving your car?
[select name="variable_14" value="Yes,    often|Sometimes|No|N/A    I    don't    drive"]

How often during the past four weeks have you been  bothered by any of the following problems?
Falling or dizzy when standing up:    [select name="variable_15" value="Never|Seldom|Sometimes|Often|Always"]
Sexual problems:    [select name="variable_16" value="Never|Seldom|Sometimes|Often|Always"]
Trouble eating well:    [select name="variable_17" value="Never|Seldom|Sometimes|Often|Always"]
Teeth or denture problems:    [select name="variable_18" value="Never|Seldom|Sometimes|Often|Always"]
Problems using the telephone:    [select name="variable_19" value="Never|Seldom|Sometimes|Often|Always"]
Tiredness or fatigue:   [select name="variable_20" value="Never|Seldom|Sometimes|Often|Always"]

Have you fallen two or more times in the past year?    [select name="variable_21" value="Yes|No"]   

Are you afraid of falling?    [select name="variable_22" value="Yes|No"]   

Are you a smoker?    [select name="variable_23" value="No|Yes,    and    I    might    quit|Yes,    but    I'm    not    ready    to    quit"]   

During the past four weeks, how many drinks of wine, beer, or other alcoholic beverages did you have? [select name="variable_24" value="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."]

Do you exercise for about 20 minutes three or more days a week?
[select name="variable_25" value="Yes, most of the time|Yes, some of the time|No, I usually do not exercise this much"]

How confident are you that you can control and  manage most of your health problems? 
[select name="variable_26" value="Very confident|Somewhat confident|Not very confident|I do not have any health problems"]

What is your race? (Check all that apply.) 
[checkbox name="variable_27" value="White|Black    or    African    America|Asian|Native    Hawaiian    or    other    Pacific    Islander|American    Indian    or    Alaskan    Native|Hispanic    or    Latino  origin    or    desent|Other"]

BIMS
[textarea name="variable_28" default=""]

PHQ9
[textarea name="variable_29" default=""]
During the past four weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad, or downhearted and blue?


During the past four weeks, has your physical and emotional health limited your social activities with family, friends, neighbors, or groups?


During the past four weeks, how much bodily pain have you generally had?


During the past four weeks, was someone available to help you if you needed and wanted help? (For example, if you felt very nervous, lonely, or blue; got sick and had to stay in bed; needed someone to talk to; needed help with daily chores; or needed help just taking care of yourself.)


During the past four weeks, what was the hardest physical activity you could do for at least two minutes?


Can you get to places out of walking distance without help? (For example, can you travel alone on buses or taxis, or drive your own car?)


Can you go shopping for groceries or clothes without someone’s help?


Can you prepare your own meals?


Can you do your housework without help?


Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house?


Can you handle your own money without help?


During the past four weeks, how would you rate your health in general?


How have things been going for you during the past four weeks?


Are you having difficulties driving your car?


How often during the past four weeks have you been bothered by any of the following problems?
Falling or dizzy when standing up:
Sexual problems:
Trouble eating well:
Teeth or denture problems:
Problems using the telephone:
Tiredness or fatigue:

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

Are you afraid of falling?

Are you a smoker?

During the past four weeks, how many drinks of wine, beer, or other alcoholic beverages did you have?

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


How confident are you that you can control and manage most of your health problems?


What is your race? (Check all that apply.)


BIMS


PHQ9

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.93, 29 form elements, 364 boilerplate words, 2 text areas, 1 checkboxes, 26 drop downs, 35 total clicks
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