Annual Wellness Visit Questions

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Annual Wellness Visit Questions

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Introduction (Show the following message at the beginning): Hello, my name is Emma and I am going to help you complete the questionnaire portion of your Annual Wellness Visit. The information that you provide will be summarized for your physician and is needed to complete the exam. This process will take about 30 minutes to complete. If you must stop, you can come back at a later time to finish. If you want me to repeat a question, just say “repeat”. Are you ready? (Section 1). Patient Please spell your full name and date of birth. [can we display the name and ask the patient if it is correct and if not ask the patient to spell it out? Can we have the patient confirm the date of birth? ] Please specify your gender. such as Male, Female. (Section 2). List of Current Providers Please say and spell the name of your primary care physician. Do you have any other physicians that you see regularly? If no, move on, If yes say Please say and spell the name of other physicians that you see and include the specialty. For example, Dr. Smith, S M I T H, cardiology. Do you see any other physicians? (repeat after each physician if there is a >2 second pause. Move on if the answer is no.) (Section 3). Patient’s Medical and Family History What medical conditions are you treated for? (repeat if there is >2 second pause. Move on if the answer is none.) Have you had any surgery in the past? If yes, ask what type of surgery? If there is a >2 second pause ask “any other surgeries and repeat if there is a >2 second pause. Move on if the answer is no.) Have you been hospitalized in the past? If no move on. If yes, When were you hospitalized and for what conditions? Any other hospitalizations? If no move on. If yes, when and for what condition, Do you take prescription medications? If no, move on, If yes, ask Which prescription medication do you take? It’s ok to spell them out. Be sure to tell me the dosage and how many times a day you take it? Any other medication? (Repeat after each medication if there is a >2 second pause. Move on if the answer is no.) [we should have the patient confirm the medication by viewing on the screen ] Are you allergic to any medication? (If yes ask “which one”) Any other medication allergies? (Repeat if there is a > 2 second pause. Move on if the answer is no.) Are you allergic to anything besides medicine? If yes ask “what are you allergic to” Any other allergies? (Repeat if there is a > 2 second pause. Move on if the answer is no.) Do you take any over the counter medications or supplements? If yes ask “which one”. Any other over the counter medication or supplements? (Repeat if there is a > 2 second pause. Move on if the answer is no.) Please tell me about your family’s medical history. What diseases have occurred in your family and in which family member. Any others?”. (Repeat if there is a >2 second pause, Move on if the answer is no.) (Section 4). Health Risk Assessment Do you drink alcoholic beverages? If yes, ask the following 2 questions. Move on if the answer is no. If Yes, how many drinks do you have each week on average. If yes, what type of alcoholic beverage do you drink? Do you currently smoke cigarettes? If yes ask “How many cigarettes do you smoke each day? For how many years have you smoked?, Are you ready to quit?” Move on if the answer is no. Did you smoke cigarettes in the past? If yes ask “How many cigarettes did you smoke each day? How many years did you smoke? When did you quit?” Move on if the answer is no. Do you use any other tobacco products? If yes ask “which ones?” If no, move on. Do you use any illegal drugs? If yes, ask “Please tell me which ones and how often” Move on if the answer is no. Are you sexually active? If no, move on. If yes ask “are you in a monogamous relationship? Would you liked to be checked for sexually transmitted diseases? In general, would you say your health is? Excellent, Very good, good, fair, poor Do you have difficulty remembering things? Do family members report that you have difficulty remembering things? How often is stress/anger a problem for you? Rarely if ever, sometimes, often, always How well do you handle the stress/anger in your life? Very well, ok or not so well How often do you get the social and emotional support you need? Always, Usually. Sometimes, Rarely, Never How often do you brush your teeth? Do you visit the dentist regularly? In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food? Do you a healthy diet that includes lots of vegetables and fruits but low on processed food like hot dogs, cakes, sugary drinks? Do you exercise? If yes ask “How many days a week do you usually exercise? On days when you exercise, for how long do you usually exercise? What type of exercise do you do?” if no, move on (Section 5). Biometrics What was your blood pressure the last time it was checked? Have you ever been told that you have high cholesterol? Have you ever been told by a doctor that you have diabetes? How about high blood pressure? What is your height? What is your weight? (Section 6). Depression Assessment Over the last 2 weeks, how often have you had little interest or pleasure in doing things? Not at all, Several days, more than half the days, nearly every day Over the last 2 weeks, how often have you been feeling down, depressed or hopeless? Not at all, Several days, more than half the days, nearly every day. (Instructions for scoring above questions: Not at all for 0, several days for 1, more than half the days for 2, nearly every day for 3; Get total score of above two questions, it is the score of PHQ 2. if the total score is 2 or more, then Emma will ask the following questions) Over the last two weeks, how often have you had trouble falling or staying asleep, or sleeping too much? Not at all, Several days, More than half the days, Nearly every day Over the last two weeks, how often have you been feeling tired or having little energy? Not at all, Several days, More than half the days, Nearly every day Over the last two weeks, how often have you had poor appetite or overeating? Not at all, Several days, More than half the days, Nearly every day Over the last two weeks, how often have you been feeling bad about yourself - or that you are a failure or have let yourself or your family down? Not at all, Several days, More than half the days, Nearly every day Over the last two weeks, how often have you had trouble concentrating on things, such as reading the newspaper or watching television? Not at all, Several days, More than half the days, Nearly every day Over the last two weeks, how often have you been moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual? Not at all, Several days, More than half the days, Nearly every day Over the last two weeks, how often have you had thoughts that you would be better off dead, or of hurting yourself in some way? Not at all, Several days, More than half the days, Nearly every day (Instructions for scoring above 9 questions: Not at all for 0, several days for 1, more than half the days for 2, nearly every day for 3; Get total score of above 9 questions, it is the score of PHQ 9) (Section 7). Functional Ability and Safety The next questions are about how well you can take care of yourself. Do you need help with the telephone? Do you need help eating, bathing, getting dressed or using the toilet? Do you need help with shopping or preparing meals? Do you need help with managing money or your medication? Do you need help with laundry? Have you fallen in the past year? Do you feel unsteady when you walk? Do you feel dizzy when you get up from a bed or chair? Does your home have rugs in the hallways? Does your home have grab bars in the bathroom? Is there any clutter in your walking space at home? The next questions are about your hearing. Do people complain that you turn the TV volume up too high? Do you find yourself asking people to repeat themselves? Do you have trouble hearing in a noisy background? Do you always fasten your seat belt when you are in the car? Do you ever drive after drinking alcohol, or ride with a driver who has been drinking? Do you protect yourself from the sun when you are outdoors by using sun screen? Do you ride a bike, scooter or go skiing? (If no move on, if yes ask Do you always wear a helmet for these activities?) (Section 8!). Screening and Vaccination Have you had the latest flu shot? (If yes ask When?) Have you ever received a pneumonia vaccine? (If no, move on. If yes, ask Do you know which one? When did you receive it?) Have you had the 2 doses of shingles vaccine? (If no, move on. If yes ask When?) Did you receive a tetanus, diphtheria, and pertussis (Tdap) booster within the last 10 years? (If no, move on. If yes ask When?) Have you received the COVID-19 vaccine and any recommended boosters? (If no, move on. If yes, ask When was your last COVID booster?) Have you received the RSV Vaccine? (If no, move on. If yes ask When?) When was the last time you had a colonoscopy? (If never, move on. If yes ask, Were polyps or cancer found?) Did you ever have a stool test for colon cancer? (If no, move on. If yes, ask When?) (For women only): When was your last mammogram? (For women only): Have you had a Pap smear or HPV test in the last 3-5 years? (For men only): Have you had a blood test for prostate cancer? (If no, move on. If yes, ask When.) (For smokers or former smokers only): "Have you ever had a lung cancer screening with a low-dose CT scan? When is the last time you saw an eye doctor? (For women only): Have you ever had a bone density test to check for osteoporosis? (If yes, ask When?) (Section 9). Advance Care Planning Do you have an Advance Directive, Living Will or Power of Attorney for Health Care (POA), in the case that an injury or illness causes you to be unable to make healthcare decisions? Would you like more information regarding Advance Directives? (Section 10). Pain and Pain Medication Do you have pain that interferes with performing desired activities? Do you take pain medication? (If yes, ask “what pain medication do you take?” If no, move on.) (Section 11). Cognitive Ability I am now going to ask you some questions to test your mental ability. What day of the week is it? What is the year? What state are we in? Please remember these five objects. I will ask you what they are later. - Apple Pen Tie House Car You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20. - How much did you spend? (correct answer get 1) - How much do you have left? (correct answer get 1) Please name as many animals as you can in one minute. (Instructions for scoring: 0-4 animals get 0, 5-9 animals get 1, 10-14 animals get 2, 15+ animals get 3) What were the five objects I asked you to remember? I am going to give you a series of numbers and I would like you to give them to me backwards. For example, if I say 42, you would say 24. - 87 (correct answer get 0) - 648 (correct answer get 1) - 8537 (correct answer get 1) This is a clock face. Please put in the hour markers and the time at ten minutes to eleven o’clock.  - (draw_zone: [clock_panel_picture ]{ 0, 0, 320, 320 }) (correct answer get 1) (Instructions for scoring: Hour markers okay get 2, Time correct get extra 2) Please place an X in the triangle.  - (draw_zone: [triangle-picture ]{ 0, 0, 179, 87 }) (correct answer get 1) Which of the the figures is largest.  (correct answer get 1) I am going to tell you a story. Please listen carefully because afterwards, I'm going to ask you some questions about it. *Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a devastatingly handsome man. She married him and had three children. They lived in Chicago. She then stopped work and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after.* - What was the female’s name? (preference: name could be Jill) (correct answer get 2) - When did she go back to work? (correct answer get 2) - What work did she do? (correct answer get 2) - What state did she live in? (correct answer get 2) (Instructions for scoring Cognitive Ability, it is the total score of above questions. For HIGH SCHOOL EDUCATION user, 27-30 means NORMAL, 21-26 means MILD NEUROCOGNITIVE DISORDER, 1-20 means DEMENTIA; For LESS THAN HIGH SCHOOL EDUCATION user, 25-30 means NORMAL, 20-24 means MILD NEUROCOGNITIVE DISORDER, 1-19 means DEMENTIA) End. (Show the following information when questionary complete) Thank you for your time! Your information has been saved. We’ll share this with your healthcare provider. You’re all set! We’ll contact you soon with your appointment details. If you have any questions, call us directly. we will see you at your appointment.