Health Risk Assessment Questionnaire 口 Good 口 Fair 口 Poor 口



Medicare Wellness Visit

 Welcome to Medicare Visit

Office Use Only:

Health Risk Assessment Questionnaire

HRA Template 1

Name: _____________________________ Date of Birth: ________________________________

In general, would you say your health is?

 Excellent

 Good

 Fair

 Poor

In general, how satisfied are you with your life?

 Very satisfied

 Satisfied

 Dissatisfied

 Very Dissatisfied

In the past 7 days, how much pain have you felt?

 None

 Some

 A lot

Do you usually exercise at least 30 minutes or more, 5 days a

week?

 Yes

 No

Do you usually eat a diet that has at least 4 servings of fruit &

vegetables, includes whole grain & fiber and avoids other

than occasional servings of high fat foods?

 Yes

 No

How would you describe the condition of your mouth and

teeth (including false teeth or dentures)?

 Excellent

 Good

 Poor

In a typical week, how much alcohol do you drink?

 None

 One drink per day or less

 Two drinks per day

 More than 2 drinks per day

Do you ever have 5 or more alcoholic drinks on one occasion?

 Yes

 No

Do you always fasten your seat belt when you are in the car?

 Yes

 No

Do you know where to locate and properly use a first aid kit

and fire extinguisher in case of an emergency?

 Yes

 No

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?

 Yes

 No

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?

 Yes

 No

In the past 7 days have you had any problems staying or

falling asleep?

 Yes

 No

In the past 7 days have you had problems with constipation?

 Yes

 No

In the past year have you had:

 2 or more falls or a fall with an injury

 No falls or 1 fall with no injury

Does your home have rugs in the hallway?

 Yes

 No

Does your home have grab bars in the bathroom?

 Yes

 No

Does your home have handrails on the stairs?

 Yes

 No

Does your home have good lighting?

 Yes

 No

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