MGH Beacon Hill Primary Care
Medicare Annual Health Assessment
For Office Use Only
Reviewed By
Date___________
Name_________________________________________________________________
Please indicate your response for each question.
General Health
1. How would you describe your physical health?
Good
Very good
Fair
Poor
2. How would you describe your quality of life?
Very good
Good
Fair
Poor
Emotional Health
1. Over the past 2 weeks, have you had little interest in doing things?
Every day
Most days
Rarely
Never
2. Over the past 2 weeks, have you felt any of the following emotions?
Anger
Isolation
Loneliness
Stress
3. Over the past 2 weeks, have you felt down, depressed or hopeless?
Every day
<Continued>
Most days
Rarely
Never
Lifestyles and Health Habits
1. Over the last week, how many days have you eaten a serving of fruit or vegetables?
4 to 6 days
Every day
1 to 3 days
None
2. Over the last week, how many days have you eaten cheese?
4 to 6 days
Every day
1 to 3 days
None
3. Over the last week, how many days have you eaten red meat?
4 to 6 days
Every day
1 to 3 days
None
4.During the past week, how many days did you do moderate physical activities
like walking, yoga, tai chi and stretching classes?
3 to 5 days
More than 5 days
1 to 2 days
Rarely
5.During the past week, how many days did you do vigorous physical activities
such as power walking, jogging, aerobic classes or swimming?
3 to 5 days
More than 5 days
1 to 2 days
Rarely
6. Are you sexually active?
No
Yes
7. Would you like to lose weight?
No
Yes
a. If yes, how much weight would you like to lose?
More than 25 pounds
16 to 25 pounds
6 to 15 pounds
1 to 5 pounds
8. How often do you use seat belts when you drive or ride in a car?
Sometimes
Always
Rarely
Never
Never drive or ride in a car
9. Do you smoke cigarettes or cigars?
No
Yes
a. If yes, how often do you smoke?
Every day
4 to 6 days a week
1 to 3 days a week
Occasionally
10.How often do you have an alcoholic beverage?
2 to 3 times a week
More than 4 times a week
2 to 4 times a month
Less than monthly
11.How many alcoholic beverages do you have on a typical day?
More than 10
7 to 9
5 or 6
3 or 4
1 to 2
12.How often do you have 6 or more drinks on one occasion?
Daily
<Continued>
Weekly
Less than monthly
Never
None
Personal Safety
1. Do you have someone you could call if you needed help?
No
Yes
2.How often do you carry out physical activities such as walking,
climbing stairs, carrying groceries or moving a chair?
Always
Often
Sometimes
Rarely
Never
3. Do you have difficulty doing the following activities?
Dressing
Walking
Bathing
Grooming
Eating
Getting in or out of chairs
Using the restroom
None of the above
4. In the past week, did you need help with any of the following activities?
Housekeeping
Taking medicines
Banking
Traveling
Preparing food
Shopping
Using the telephone
None of the above
5. In the past year, have you experienced difficulties with balancing or walking?
No
Yes
6. In the past year, have you fallen?
No
Yes
7. Do your finances cover the basic necessities such as food, clothing or housing?
Sometimes
Always
Rarely
8.Are you currently in a relationship where you were threatened,
controlled, physically hurt or made to feel afraid?
Yes
No
9. Do you have oral problems that make it hard for you to eat?
No
Yes
10. Do you have any hearing problems?
No
Yes
a. If yes, do your hearing problems limit or hamper your life?
Yes
No
11. Who is taking this health questionnaire?
Patient
Family member
Friend
Health care provider
Translator
Other_______________________________________________________________
<Continued>
Personal History
12. Have any family members died or contracted a serious illness in the last year?
Yes
No
If yes, please describe______________________________________________
13. Have there been any major changes in your life?
Yes
No
If yes, please describe______________________________________________
14.Please list any doctors’ offices you have visited since your last visit
(include contact information if available).
______________________________________________________________________
______________________________________________________________________
15. Please list any screening tests or procedures you have had since your last visit.
______________________________________________________________________
______________________________________________________________________
16. Please list any vaccinations you received since your last visit.
______________________________________________________________________
_____________________________________________________________________
17. Please indicate if you have concerns regarding any of the following:
Abdominal pain
Blood in stool
Chest pain
Cough
Difficulty speaking
Frequent nosebleeds
Heartburn/indigestion
Joint pain/swelling
Memory loss
Nausea/vomiting
Rash
Severe or new headaches
Swollen glands
Wheezing or asthma
<Continued>
Ankle or leg swelling
Blood in urine
Change in mole or new mole
Coughing up blood
Difficulty swallowing
Frequent urination
Hoarseness
Leg cramps
Mouth sores
Night sweats
Ringing in ears
Shortness of breath
Sudden change in vision
Unusual fatigue
Bruising
Burning urination
Constipation
Diarrhea
Fainting or blackouts
Hearing loss
Jaundice
Loss of balance
Muscle cramps
Palpitations
Seizures
Sinus problems
Weight change
Urinary incontinence
Female Patients Only
Please indicate if you have concerns regarding any of the following:
Abnormal mammogram
Abnormal pap smear
Breast lump
Breast pain
Bleeding between periods
Cessation of periods
Changes in sexual interest
Irregular periods
Hot flashes
Vaginal discharge
Other problems__________________________________________________________
Male Patients Only
Please indicate if you have concerns regarding any of the following:
Changes in sexual interest
Decreased urinary stream
Difficulty urinating
Frequent nighttime urination
Lump(s) in testicle
Other problems__________________________________________________________