Health Risk Assessment Questionnaire This questionnaire is required for all First and Subsequent Annual Wellness Visits (AWV) and is used for Welcome to Medicare Visits (also called …

HEALTH RISK ASSESSMENT 8750-9693 11:17 JR Page 2 of 5 FUNCTIONAL STATUS ASSESSMENT, CPT II CODE 1170F Instrumental activities of daily living 23. Which of the …

risk questionnaire In general, compared to other people your age, would you say that your health is: Poor Fair Good Very good Excellent

Medicine Partners, Stanford Health Care, Stanford Health Care Tri-Valley, or Stanford University. To ensure optimal care coordination, please list below all providers you see on a regular basis.

Download this free Health Risk Assessment Questionnaire PDF to identify health risks and assess your patient's health profile.

Health Risk Assessment Please complete the entire questionnaire completely so that your provider has complete and up to date information about you. Bring this with you to your …

ups, health screenings, and disease prevention. I limit my alcohol: consumption to. within the recommended guidelines. Safety: 1 Never: 2 Almost: never 3 Occasionally: 4 Almost: always 5 …

This Health Risk Assessment Questionnaire is part of your upcoming Wellness Visit. Please answer the following questions about your health and day to day activities. This questionnaire …

Does the patient have any of the following behavioral health conditions (specify Dx below)? Reviewed and documented list of current medications, dosage, and last refill date? Yes (Must …

In order for Medicare to pay for a wellness visit, the patient MUST complete a Health Risk Assessment form. Please take the time to fill it out prior to your visit.