Health Wellness QuestionnaireSELF ASSESSMENT OF HEALTH: Please check one response for each question: Date MM DD YYYY Date of Birth * Physician Name * Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Country (###) ### #### SELF ASSESSMENT OF HEALTH: Please check one response for each question: * How do you rate your overall health the past 4 weeks? Excellent Good Fair Poor Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house? * Yes No PSYCHOSOCIAL HEALTH: Please check one response for each question: * In the past 2 weeks, how often have you been bothered by the following: Feelings that caused you distress or interfered with your ability to get along socially with family or friends? Not at all Several days More than half the days Nearly everyday Feeling stress over health, finances, relationships, or work? * Not at all Several days More than half the days Nearly everyday 6) In the past 7 days, how much did your pain interfere with your day-to-day activities? * Not at all Several days More than half the days Nearly everyday Fatigue? * Not at all Several days More than half the days Nearly everyday HEALTH AND HABITS: Please check one response for each question: * In the past 7 days, how many days did you exercise? 1-3 days 3-5 days Every Day Not at All How intense is your typical exercise? * Light (like stretching or slow walking) Moderate (like a brisk walk) Heavy (like jogging or swimming) Very heavy (like fast running or stair climbing) I am currently not exercising In the past 7 days, how often did you eat 3 or more servings of fruits and vegetables in a day? * Not at al Several days More than half the days Nearly every day FUNCTIONAL EVALUATION * Do you have trouble walking? Yes No Do you need help climbing stairs? * Yes No Do you need help with bathing? * Yes No Do you need help with dressing? * Yes No Do you need help with telephone use? * Yes No Do you need help with transportation? * Yes No Do you need help with shopping? * Yes No Do you need help with preparing meals? * Yes No Do you need help with housework? * Yes No Do you need help with laundry? * Yes No Do you need help with taking medications? * Yes No Do you need help with managing money? * Yes No Do you have trouble concentrating, remembering, or making decisions? * Yes No In the past 12 months, have you fallen? * Yes No By checking this box I give permission to my physician to enroll me into his/her Chronic Care Management program. * I Consent Thank you!
