老了，老老实实去做年检。Dr. 的助手让我填了如下问卷，该 Yes 的都 Yes； 该 No 的都 No。
Dr. 㸔了结果说: “Very good!”
No. 20 大笑
No. 19 喝热水
No. 18 吃坚果
No. 17 吃大蒜
No. 16 喝茶
No. 13 吃绿叶菜
No. 12 保持镇静
No. 11 少吃糖
No. 9 高质量睡眠
No. 8 吃姜
No. 7 不要久坐
No. 6 陪伴
No. 5 保持开心
No. 4 按摩
No. 3 拥抱
No. 2 跑步
No. 1 喝酒
Medicare Annual Wellness Exam
Please answer as many of the items below as possible. If you are unsure, leave items blank, and we can. discuss during your exam. Thank you!
Please circle YES or NO for the items below.
YES NO Do you require assistance preparing food and eating?
YES NO Do you require assistance bathing?
YES NO Do you require assistance getting dressed?
YES NO Do you require assistance usingthe toilet?
YES NO D9 you require assistance moving around from place to place?
YES NO Do you require assistance with household management? (Cleaning, laundry, chores, etc)
YES NO Do you require assistance handling your money (finances)?
YES NO Do you have any hearing difficulties? (LEFT! RIGHT! BOTH)
YES NO Do you wear hearing aids? (LEFT! RIGHT/ BOTH
YES NO Do you have any vision difficulties? (LEFT! RIGHT/ BOTH)
YES NO Do you wear corrective lenses? LEFT! RIGHT! BOTH)
YES NO Do you have trouble with urinary leakage?
YES NO Do you use an ostomy bag?
YES NO Are you following a special diet?
YES NO Over the past 2 months, have you felt down, depressed, or hopeless?
YES NO Over the past 2 months, have you felt little interest or pleasure in doing things?
YES NO In the last 12 months, have you visited an Emergency Room outside of Overlake?
YES NO In the last 12 months, have you been hospitalized outside of Overlake?
YES NO In the last 12 months, have you seen any specialists outside of Overlake?
Do you use any of the following equipment at home?
9 CANE o WALKER O BEDSIDE COMMODE
O TUB SEAT o OYGEN/RESPIRATORY TREATMENT o WHEELCHAIR
·HOSPITAL BED O I DO NOT USE ANY EQUIPMENT LISTED
Are you currently exercising? YES NO JAM UNABLE TO EXERCISE
If you are, what kinds of exercise are you doing?
In the past year, have you fallen or had a near fall? NO FALLS ONE FALL TWO OR MORE FALLS
Have you been injured in any of your falls? YES NO
Do we have a P01ST (Physician Orders for Life Sustaining Treatment) or Advance Directives for you? YES NO