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Annual Wellness Visit (AWV) Health Risk Assessment
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FALL RISK SCREEN
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Wheelchair Bound
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Timed Up and Go [Default off]
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Time to get up & walk
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Do you have any trouble with gait or balance?
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Have you had a fall WITH injury?
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Have you had 2 or more falls last 12 months?
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Is the patient’s home safe
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IF there are Home safetly concerns, please choose here
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Health Status according to patient
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What impacts managing your health
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Diet as described by patient
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Patient Currently Exercises
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Hospital Admits in the last 6 months
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Emergency room visits in the last 6 months
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Urinary incontinence
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If Yes to Incontinence when?
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Vision difficulties
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Vision Eval-- [Pick NO if not done]
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Ever has deafness or trouble hearing?
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Hearing Eval-- [Pick NO if not done]
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Can understand normal voice across room w/out hearing aid ?
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Can understand whisper across room w/out hearing aid ?
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MINI COGNITIVE SCREENING [Default off]
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Cognitive Eval-- [Pick NO if not done]
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PEN, TABLE, CHAIR
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New Short Text Field
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Word Recall Score [3 points]
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Cognitive Score [Words + Clock] < 3 needs evaluation
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Uploaded Clock Image
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Psychosocial Questions-NO anger/isolation/HAS interactions
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ADVANCED CARE PLANNING [Default off]
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Advance Directive [Available]
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Advance care planning [Accepted/Refused]
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FUNCTIONAL ABILITY [Default off]
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Assisted Living---{Default OFF ]
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Activites of Daily Living
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Instrumental Activities of Daily Living
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Self reliant or NOT [Independent and autonomous]
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DEPRESSION SCREENING
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Depression Screening
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Depression screening not completed:
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Feels down depressed / Hopeless
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Loss of interest / Pleasure
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Preventive Care [Default off]
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Immunization Records- [Pick NO if not available]
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Immunizations Needed
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Preventive testing up to date
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Patient is currently prescribed an Opioid from Dr. Sarah
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Schedule of Preventive Services provided to patient
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