Elewell Care Integrative
Annual Wellness Questions
Please answer the following questions
1
Please list all doctors that you have seen in the past year and the speciality
On File
2
Please list all any medications you are currently taking
On File
3
Please list any tests you have done in the past year such as blood tests, colonoscopy, mammograms, CT Scan, MRI, etc)
On File
4
Have you had any recent immunizations?
Yes
No
5
Do you have a living will or advance directive?
Yes
No
6
Can you get places out of walking distance without help? *For example, can you travel alone by bus, taxi, or drive your own car?
Yes
No
7
Can you shop for groceries or clothes without help?
Yes
No
8
Can you prepare your own meals?
Yes
No
9
Can you do your own housework without help?
Yes
No
10
Can you handle your own money without help?
Yes
No
11
Do you need help eating, bathing, dressing, or getting around your home?
Yes
No
12
Have you been given any information to help you keep track of your medications?
Yes
No
13
Have you been given any information to help you identify hazards in your house that might hurt you?
Yes
No
14
Have you fallen two (2) or more times in the past year?
Yes
No
15
How often in the past 4 weeks, have you had problems using the telephone?
Never
Seldom
Sometimes
Often
16
How often in the past 4 weeks, have you had trouble eating well?
Never
Seldom
Sometimes
Often
Always
17
How often in the past 4 weeks, have you been bothered by your teeth or dentures?
Never
Seldom
Sometimes
Often
Always
18
During the past 4 weeks, was someone available to help you if you needed and wanted help? *For example, if you felt very nervous, lonely or blue, got sick and had to stay in bed, needed someone to talk to, needed help with daily chores, or needed help just taking care of yourself.
Yes, as much as I wanted
Yes, quite a bit
Yes, some
Yes, a little
No, not at all
19
Are you having difficulties driving your car?
No
Sometimes
Yes, often
Not applicable, I do not use a car
20
How confident are you that you can control and manage most of your health problems?
Very confident
Somewhat confident
Not very confident
I do not have any health problems
21
How often do you have trouble taking medicines the way you have been told to take them?
I do not have to take medicine
I always take them as prescribed
Sometimes I take them as prescribed
I seldom take them as prescribed
22
Do any family members have a personal history of any of the following?
None
Alcohol/Drug Abuse
Allergies
Arthritis
Asthma
Bleeding/Blood Disorder
Cancer
COPD
Depression
Diabetes
Gastrointestinal Problems
Genetic Diseases/Birth Defects
Genitourinary Problems
Headaches
Heart Problems
High Cholesterol
Hypertension
Kidney Disease
Mental Illness
Musculoskeletal Disorders
Nervous System Disorders
Obesity
Osteoporosis
Sickle Cell Anemia
Stroke
Thyroid Disease
Tuberculosis
Eye Problems