Subjective – Medicare Health Risk Assessment

MEDICARE HEALTH RISK ASSESSMENT

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 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 value="|Not at all.|Slightly.|Moderately.|Quite a bit.|Extremely."]

During the past four weeks, how much bodily pain have you generally had?
[select 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 value="|Yes, as much as I wanted.|Yes, quite a bit.|Yes, some.|Yes, a little.|No, not at all."]

During the past four weeks, what was the hardest physi-cal activity you could do for at least two minutes?
[select 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 value="|Yes.|No."]

Can you go shopping for groceries or clothes without some-one’s help?
[select value="|Yes.|No."]

Can you prepare your own meals?
[select value="|Yes|No."]

Can you do your housework without help?
[select value="|Yes.|No."]

Because of any health problems, do you need the help of another person with your personal care needs such as eat-ing, bathing, dressing, or getting around the house?
[select value="|Yes.|No."]

Can you handle your own money without help?
[select value="|Yes.|No."]

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

How have things been going for you during the past four weeks?
[select 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 value="|Yes, often.|Sometimes.|No.|Not applicable, I do not use a car. "]

Do you always fasten your seat belt when you are in a car?
[select value="|Yes, usually.|Yes, sometimes.|No. "]

How often during the past four weeks have you been bothered by any of the following problems?


Falling or dizzy when standing up.
[select value="|Never.|Seldom.|Sometimes.|Often.|Always."]

Sexual problems.
[select value="|Never.|Seldom.|Sometimes.|Often.|Always."]

Trouble eating well.
[select value="|Never.|Seldom.|Sometimes.|Often.|Always."]

Teeth or denture problems.
[select value="|Never.|Seldom.|Sometimes.|Often.|Always."]

Problems using the telephone.
[select value="|Never.|Seldom.|Sometimes.|Often.|Always."]

Tiredness or fatigue.
[select value="|Never.|Seldom.|Sometimes.|Often.|Always."]

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

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

Are you a smoker?
[select 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 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 value="|Yes, most of the time.|Yes, some of the time.|No, I usually do not exercise this much."]

Have you been given any information to help you with the following:

Hazards in your house that might hurt you?
[select value="|Yes.|No."]

Keeping track of your medications?
[select value="|Yes.|No. "]

How often do you have trouble taking medicines the way you have been told to take them?
[select value="|I do not have to take medicine.|I always take them as prescribed.|Sometimes I take them as prescribed.|I seldom take them as prescribed."]

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

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

Thank you very much for completing your Medicare Wellness Checkup.