ࡱ> KMJ r bjbj++ 7DIIVBBBBBVVV8V0nnnnnIIIOQQQQQQ$ZuBIIIIIuBBnnIFBnBnOIOn\sF;0   BHIIIIIIIuuIIIIIII IIIIIIIII :  How would you describe your Health?GoodFairPoor Were you hospitalized in the last year?YesNo Has it been more than one year since your last dental visit?YesNo Has it been more than one year since your last eye doctor visit?YesNoDo you have trouble with your vision?YesNo Do you have trouble dressing, bathing, eating, using the toilet or grooming?YesNoDo you have trouble doing errands alone, such as visiting your doctor or shopping?YesNoDo you have trouble making food, doing housework or using the phone?YesNoDo you have trouble using your checkbook or paying bills?YesNo Do you have trouble understanding and/or taking your medications?YesNoIf you drive, have you had any car accidents while driving in the last 12 months?YesNoDo Not DriveAre you or someone close to you concerned about your memory?YesNoDo you have trouble concentrating on things, remembering things or making decisions?YesNoDo you have difficulty walking or climbing stairs?YesNo How many days per week do you exercise?None1 to 3 days4+ days How do you describe your pain levels?Moderate- SevereMildNoneHow would you rate your diet?GoodFairPoor How frequently do you eat fruits, vegetables, fiber and whole grain products?RarelySometimesDaily     MEDICARE WELLNESS VISIT HEALTH RISK ASSESSMENT QUESTIONNAIRE 456fgh' ( ) ~  ( ) c f g i k l m       [ \ _ ` b d e B C       ! 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