DR. NALINI YELAMANCHI

Patient Forms

Forms

Patient Forms

Medicare Wellness Visit Patient Questionnaire

Please complete this questionnaire before your visit and bring it with you along with all of your current medications.

Advance Care Planning

Information about your advance directives

Do you have an advance directive or living will?

Yes

Don't Know

Do you have a healthcare proxy or surrogate decision maker?

Yes

Don't Know

*If yes, please bring a copy for your chart!

Provider List

If this is not your first Medicare Wellness visit, please list new providers since your last visit.

Please include doctors and other suppliers of care like personal care assistant, home health aide, adult day care, home delivered meals, etc.

Provider Name

Provider Location

Provider Phone

Mental Health Assessment

How have you been feeling in the past two weeks?

Question	Not at All	Several Days	More than half the days	Nearly every day
Have you been bothered by little pleasure in doing things?
Have you been bothered by feeling down depressed or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Do you feel tired or have too little energy?
Poor appetite or overeating?
Feeling bad about yourself or that you are a failure or have let yourself or your family down?
Trouble concentrating on things, such as reading the newspaper or watching television?
Moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual?
Thoughts that you would be better off dead, or of hurting yourself?

Stress & Social Assessment

Questions about stress and social connections

Question	Hardly Ever	Sometimes	Often
How often is stress a problem for you in handling your health, finances, family or social relationships?
In the past 7 days, how often have you felt angry?
How often do you feel you lack companionship?
How often do you feel left out?
How often do you feel isolated from others?

Memory & Dental Concerns

Questions about memory and dental health

Question	No	Yes
Do you have concerns about your memory?
Have family or friends been concerned about your memory?
Do you have concerns about sex?
Do you have problems with your teeth or gums?
Do you have dentures?
Do you see a dentist?
Does anyone have concerns about your hearing?

Vitamins & Diet

Information about your vitamin intake and diet

Daily Activities

Your ability to perform daily activities

Activity	Able to	Not able to	Find it difficult to
Dress yourself
Feed yourself
Toilet yourself
Groom yourself
Bathe yourself
Handle your finances
Obtain and take your medicines
Get in and out of a car
Walk 1-4 blocks
Walk 5-9 blocks
Walk 10 or more blocks
Go down steps
Go up steps
Kneel
Put on socks and shoes
Shop for yourself
Prepare your own food
Do your housekeeping
Do your laundry
Use a telephone

What transportation do you use?

Home Safety

Questions about safety in your home

Falls & Physical Activity

Information about falls and your physical activity level

Physical Activity

How would you describe your physical activity level?

None

You are not physically active and spend most of your time sitting or resting.

Low

You do light physical activity (able to have a normal conversation while moving).

Medium

You do some moderate physical activity (breathing harder, more difficult to talk while moving) per week.

High

You do 150 or more minutes per week of moderate physical activity, or 75 or more minutes per week of vigorous physical activity (somewhat breathless, very difficult to talk while moving).

Substance Use

Questions about alcohol, tobacco, and other substances

Alcohol

How often do you have a drink containing alcohol?

How many standard drinks containing alcohol do you have in a typical day when you drink?

How often do you have 6 or more drinks on one occasion?

Tobacco and Vaping

Question	No	Yes	If yes, what kind?	If yes, number per day?	Former User- age when quit
Do you use tobacco?
Do you vape or use electronic cigarettes?

Other Medications

Question	No	Yes
Do you take opioids (narcotics)?
Do you take drugs you obtained elsewhere?

Medical History Update

Updates to your medical history since your last visit

Family History Update

Updates to your family's health history

Parents:

Siblings:

Children:

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About Contact Us

Question	No	Yes
Did you fall in the last year?
If so, did the fall(s) result in injury?
Do you use a cane or walker?
Do you have trouble with balance?

	No	Yes	Details if yes
Illnesses since last visit
Injuries since last visit
Hospital stays since last visit
Specialists since last visit
Operations since last visit

Question	No	Yes
Do you have smoke detectors in your home?
Do you have firearms in your home?
Do you use a seat belt when in a vehicle?