Phone No.

772-783-2436

Email

[email protected]

Address

7955 Bay St - Suite 2, Sebastian, FL 32958

Book An Appointment
Book An Appointment
Book An Appointment

MEDICARE WELLNESS VISIT QUESTIONNAIRE

Name
MM slash DD slash YYYY

HEALTH STATUS

In general, how would you rate your overall health?
In general, how would you rate your overall emotional/mental health?
Do you have trouble hearing?

FUNCTIONAL ABILITY

Do you need assistance with any of the following?

MOOD

Because of physical/mental conditions, do you have difficulty concentration, remembering or making decisions?
Do you have excessive worry or stress in your life?

HOME & SAFETY

Where do you live?
Do you feel safe at home?
Who would help you if you became ill or injured?
Do you have smoke detectors?
Do you have safety bars in the bathroom?
Do you ever take your medications for reasons other than what they are prescribed for?

FALLS

How many times have you fallen in the past year and were you injured?
Do you feel unsteady or wobbly when standing or walking?
Do you worry about falling?
If recommended to use a cane or walker, do you use it consistently?

DIET

Are you generally able to eat well?
Which issues prevent you from eating well?
Do you consider your diet to be healthy?

EXERCISE

Do you participate in activities to increase your heart rate several days a week?
Do you participate in strength building activities at least twice per week?
As always, we thank you for allowing us to participate in all your healthcare needs.

Call Now

772-783-2436

Exemplifying excellence in healthcare, ‘Internal Medicine & Primary Care of Sebastian LLC,’ serves with dedication and a longstanding expertise of 17 years. Catering to adults aged 18 and upwards, we prioritize continuous care and overall well-being. Embark on a life-enhancing journey with us towards total health.

Learn More About Us
Internal Medicine & Primary Care of Sebastian LLC

Quick Links

Our Services

Contact Us

Facebook Twitter Youtube

Copyright © 2024 · Internal Medicine And Primary Care Of Sebastian LLC · Website Design by SpringHive