This list of brief health assessment questions is organized by behavior or risk and sorted alphabetically. 4-7 In some cases, you can choose one of two options (A or B, not both). Questions marked with are suitable for the Centers for Medicare & Medicaid Services (CMS) Annual Wellness Visit (AWV) health risk assessment. The topic headings are provided for your convenience, but may not be appropriate for patients to see. Select questions that are appropriate for your patient population. Reformat the questions as needed to fit with your practice flow or information systems.
ACTIVITIES OF DAILY LIVING (ADL) / INSTRUMENTAL ADL
| Activities of Daily Living (ADL) In the past 7 days, did you need help from others to perform everyday activities such as eating, getting dressed, grooming, bathing, walking, or using the toilet? | ___ No ___Yes |
| Instrumental Activities of Daily Living (ADL) In the past 7 days, did you need help from others to take care of things such as laundry and housekeeping, banking, shopping, using the telephone, food preparation, transportation, or taking your own medications? | ___ No ___Yes |
ALCOHOL USE
| MEN UNDER 65 ONLY: How many times in the past year have you had 5 or more drinks in a day? | ___ 0 ___ 1 ___ 2 ___ 3 or more times |
| ALL OTHERS: How many times in the past year have you had 4 or more drinks in a day? | ___ 0 ___ 1 ___ 2 ___ 3 or more times |
ANXIETY
| a. Over the past 2 weeks, how often have you felt nervous, anxious, or on edge? | ___ Not all ___ Several days ___ More days than not ___ Nearly every day |
| b. Over the past 2 weeks, how often were you not able to stop worrying or control your worrying? | ___ Not all ___ Several days ___ More days than not ___ Nearly every day |
DEPRESSION
| a. Over the past 2 weeks, how often have you felt down, depressed, or hopeless? | ___ Not all ___ Several days ___ More days than not ___ Nearly every day |
| b. Over the past 2 weeks, how often have you felt little interest or pleasure in doing things? | ___ Not all ___ Several days ___ More days than not ___ Nearly every day |
GENERAL HEALTH
| In general, would you say your health is: | ___ Excellent ___ Very good ___ Good ___ Fair ___ Poor |
| How would you describe the condition of your mouth and teeth, including false teeth or dentures? | ___ Excellent ___ Very good ___ Good ___ Fair ___ Poor |
| Have you suffered a personal loss or misfortune in the last year? (For example: a job loss, disability, divorce, separation, jail term, or the death of someone close to you.) | ___ No ___ Yes, one serious loss ___ Yes, two or more serious losses |
MEDICATION ADHERENCE
| How often do you have trouble taking medicines the way you have been told to take them? | ___ 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 |
NUTRITION / EATING PATTERNS