650howe ave ste730, Sacramento, CA-95825
Monday - Thursday 8.00 AM - 5.00 PM.
Email:
info@mayfairmedsacramento.com
Call: +1 916-999-4535
+1 916-999-4535
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Wellness Form
WELLNESS QUESTIONNAIRE
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
PATIENT DETAILS
Patient Name
Patient Date of Birth
Today's Date'
Last Four of SS No.
Patient Email
ADL ASSESSMENT
1. Can You Dress Yourself?
Yes
No
2. Can You Feed Yourself?
Yes
No
3. Do You Need Assistance Going To The Restroom?
Yes
No
4. Do You Need Assistance With Bathing?
Yes
No
5. Do You Do Your Own Shopping?
Yes
No
6. Do You Drive?
Yes
No
7. Do You Do Your Own Cooking?
Yes
No
8. Do You Do Your Own Laundry?
Yes
No
9. Do You Handle Your Own Finances?
Yes
No
10. Do You Take Care Of Your Own Medications?
Yes
No
11. Can You Climb 10 Steps Unassisted?
Yes
No
12. Do You Consider Yourself Overweight?
Yes
No
13. Do You Eat Fruits And Vegetables?
Yes
No
14. How Many Days A Week Do You Exercise?
15. How Many Hours Of Sleep Do You Get At Night?
16. Is There Anything We Can Do To Help You Be Healthier?
FALL RISK ASSESSMENT
1. Have You Fallen In The Past 3 Months?
Yes
No
2. Do You Feel Weak Or Unsteady On Your Feet?
Yes
No
3. Are You Often Forgetful?
Yes
No
4. Do You Use One Of The Following?
Yes
No
BEHAVIOR ASSESSMENT
1. Do You Use A Hearing Aid?
Yes
No
2. Do You Have False Teeth?
Yes
No
3. Do You See A Dentist Yearly?
Yes
No
4. Do You Wear A Seat Belt?
Yes
No
5. Do You Have Smoke Detectors?
Yes
No
6. Do You Change The Batteries In Your Smoke Detectors Yearly?
Yes
No
ALCOHOL/DRUG ABUSE OR DEPENDENCE
1. Do You Drink Alcohol?
Yes
No
2. Do You Use Recreational Drugs?
Yes
No
3. Have You Ever Felt You Should Cut Down On Your Drinking Or Drug Use?
Yes
No
4. Have People Annoyed You By Criticizing Your Drinking Or Drug Use?
Yes
No
5. Have You Ever Felt Bad Or Guilty About Your Drinking Or Drug Use?
Yes
No
6. Eye Opener: Have You Ever Had A Drink Or Used Drugs First Thing In The Morning To Steady Your Nerves Or Get Rid Of A Hangover?
Yes
No
LIVING WILL
1. Do You Have A Living Will?
Yes
No
Please Attached Your Living Will
HEART RISK ASSESSMENT
1. Do You Suffer From Chest Pain?
Yes
No
2. Do You Have Pain In Your Legs When Exercising?
Yes
No
3. Do You Suffer From Shortness Of Breath?
Yes
No
4. Do You Have Swelling In Your Legs, Feet, Or Hands?
Yes
No
5. Do You Have Vision Disturbances?
Yes
No
6. Do You See A Cardiologist?
Yes
No
7. Did Your Father Or Mother Have Heart Disease?
Yes
No
LUNG CANCER SCREENING
1. Are You A Smoker?
Yes
No
2. Have You Quit In The Last 15 Years?
Yes
No
3. Did Or Do You Smoke One Or More Packs A Day?
Yes
No
4. Have You Smoked For More Than 30 Years?
Yes
No
5. Are You 55 To 77 Years Old?
Yes
No
6. Are You Cancer-free (Never 6 Diagnosed With Lung Cancer)?
Yes
No
Note:
(If answers 1 or 2 are Yes and 3-5 are Yes or the total equals 30 pack years then candidate for CT Scan) It the patient is a never smoker or not age 55-77 -NA Do not drop codes.
PATIENT DETAILS
Patient Name
Patient Date of Birth
Date Of Services
BMI (Body Mass Index)
BP
Depression (Patient Health Questionnaire-9) - (PHQ-9)
Over The Last 2 Weeks How Often You Been Bothered By Any Of The Following Problems?
1. Little Interest Or Pleasure In Doing Things
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
2. Feeling Down, Depressed Or Hopeless
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
3. Trouble Falling Or Staying Asleep, Or Sleeping Too Much
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
4. Feeling Tired Or Having Little Energy
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
5. Poor Appetite Or Overeating
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
6. Feeling Bad About Yourself Or That You Are A Failure Or Have Let Yourself Or Your Family Down
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
7. Trouble Concentrating On Things, Such As Reading The Newspaper Or Watching Television
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
8. 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 - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
9. Thoughts That You Would Be Better Off Dead, Or Of Hurting Yourself
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
* Please Count and Enter Your Grand Total For Above Answers
10. If You Checked Off Any Problems, How Difficult Have These Problems Made It For You To Do Your Work, Take Care Of Things At Home, Or Get Along With Other People?
Not Difficult At All
Somewhat Difficult
Very Difficult
Extremely Difficult
Generalized Anxiety Disorder (GAD) Scale
Over The Last 2 Weeks, How Often Have You Been Bothered By The Following Problems?
1. Feeling Nervous, Anxious Or On Edge.
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
2. Not Being Able To Stop Or Control Worrying.
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
3. Worrying Too Much About Different Things.
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
4. Trouble Relaxing.
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
5. Being So Restless That It's Hard To Sit Still.
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
6. Becoming Easily Annoyed Or Irritable.
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
7. Feeling Afraid As If Something Awful Might Happen.
Not At All - 0
Several Days - 1
More Than Half The Days - 2
Nearly Everyday - 3
* Please Count and Enter Your Grand Total For Above Answers
Please Mark And Answer The Questions Below To The Best Of Your Ability.
1. Have You Had Any Falls Or Near Falls In Last 6 Months?
Yes
No
Not Sure
2. Since Your Last Visit, Have Any Other Doctors Changed Your Medications?
Yes
No
Not Sure
3. Do You Have A Coronary Artery Disease (CAD) Heart Disease?
Yes
No
Not Sure
4. Do You Have Diabetes?
Yes
No
Not Sure
5. Do You Believe Your Blood Pressure Is In Good Control?
Yes
No
Not Sure
6. Did You Have A Depression Screening In The Last 12 Months?
Yes
No
Not Sure
7. (Females Only) Have You Had A Mammogram In The Last 2 Years?
Yes
No
Not Sure
8. Have You Had A Colorectal Cancer Screening? This Includes A Stool Occult Blood, Colonoscopy In The Last 5 Years?
Yes
No
Not Sure
9. Have You Received An Influenza Immunization Since October 2019?
Yes
No
Not Sure
10. Have You Received A Pneumococcal Immunization After The Age 65?
Yes
No
Not Sure
11. Do You Smoke Cigarettes?
Yes
No
12. Do You Have An Advanced Care Plan/Directive?
Yes
No
13. Are You Participating In The Chronic Care Management Program?
Yes
No
14. Do You Know Your BMI (Body Mass Index)?
Yes
No
