Health Assessments in Primary Care: A How-to Guide

Appendix 4: Adult Health Assessment Sample Questions

This list of brief health assessment questions is organized by behavior or risk and sorted alphabetically.4-7 In some cases, you can choose one of two options (A or B, not both). Questions marked with Annual Wellness Visit (AWV) checkmark. are suitable for the Centers for Medicare & Medicaid Services (CMS) Annual Wellness Visit (AWV) health risk assessment. The topic headings are provided for your convenience, but may not be appropriate for patients to see. Select questions that are appropriate for your patient population. Reformat the questions as needed to fit with your practice flow or information systems.

 

ACTIVITIES OF DAILY LIVING (ADL) / INSTRUMENTAL ADL

AWV checkmark.Activities of Daily Living (ADL)
In the past 7 days, did you need help from others to perform everyday activities such as eating, getting dressed, grooming, bathing, walking, or using the toilet?
___ No
___Yes
AWV checkmark.Instrumental Activities of Daily Living (ADL)
In the past 7 days, did you need help from others to take care of things such as laundry and housekeeping, banking, shopping, using the telephone, food preparation, transportation, or taking your own medications?
___ No
___Yes

ALCOHOL USE

 MEN UNDER 65 ONLY: How many times in the past year have you had 5 or more drinks in a day?___ 0
___ 1
___ 2
___ 3 or more times
AWV checkmark.ALL OTHERS: How many times in the past year have you had 4 or more drinks in a day?___ 0
___ 1
___ 2
___ 3 or more times

ANXIETY

AWV checkmark.a. Over the past 2 weeks, how often have you felt nervous, anxious, or on edge?___ Not all
___ Several days
___ More days than not
___ Nearly every day
b. Over the past 2 weeks, how often were you not able to stop worrying or control your worrying?___ Not all
___ Several days
___ More days than not
___ Nearly every day

 

DEPRESSION

 a. Over the past 2 weeks, how often have you felt down, depressed, or hopeless?___ Not all
___ Several days
___ More days than not
___ Nearly every day
b. Over the past 2 weeks, how often have you felt little interest or pleasure in doing things?___ Not all
___ Several days
___ More days than not
___ Nearly every day

 

GENERAL HEALTH

AWV checkmark.In general, would you say your health is:___ Excellent
___ Very good
___ Good
___ Fair
___ Poor
 How would you describe the condition of your mouth and teeth, including false teeth or dentures?___ Excellent
___ Very good
___ Good
___ Fair
___ Poor
 Have you suffered a personal loss or misfortune in the last year?
(For example: a job loss, disability, divorce, separation, jail term, or the death of someone close to you.)
___ No
___ Yes, one serious loss
___ Yes, two or more serious losses

MEDICATION ADHERENCE

 How often do you have trouble taking medicines the way you have been told to take them?___ I do not have to take medicine
___ I always take them as prescribed
___ Sometimes I take them as prescribed
___ I seldom take them as prescribed

 

NUTRITION / EATING PATTERNS

AWV checkmark.Option A
Over the past 7 days:

a. How many times did you eat fast food or snacks or pizza?



___ 0
___ 1
___ 2
___ 3 or more times
 b. How many servings of fruits or vegetables did you eat each day?___ 3 or more servings
___ 2
___ 1
___ 0
 c. How many sodas and sugar sweetened drinks (regular, not diet) did you drink each day?___ 0
___ 1
___ 2
___ 3 or more sweet drinks
 Option B

Over the past 7 days, how many servings of fruits or vegetables did you eat each day?


___ 3 or more servings
___ 2
___ 1
___ 0


PAIN

 In the past 7 days, how much pain have you felt?___ None
___ Some
___ A lot

PATIENT PRIORITIES

 Which of the above health topics is the most important one to talk with your doctor about today?_____________________________________________________

PERSONAL SAFETY

AWV checkmark.Do you always fasten your seat belt when you are in a car?___Yes
___ No
 Do you ever drive after drinking, or ride with a driver who has been drinking?___ No
___Yes

 

PHYSICAL ACTIVITY

AWV checkmark.Option A
a. On how many of the last 7 days did you engage in moderate to strenuous
exercise (like a brisk walk)?

___ 7
___ 6
___ 5
___ 4 days
___ 3
___ 2
___ 1
___ 0
 On those days that you engage in moderate to strenuous exercise, how many minutes, on average, do you exercise at this level?______ minutes
AWV checkmark.Option B
In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate?
(This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job.)

___ 7
___ 6
___ 5
___ 4 days
___ 3
___ 2
___ 1
___ 0

 

SEX

 a. How many different sexual partners have you had in the past year?___ 0
___ 1
___ 2
___ 3 or more
 b. When you have sex, do you have sex with men, women, or both?___ Men
___ Women
___ Both

 

SLEEP

 a. Do you snore or has anyone told you that you snore?___ No
___ Yes
 b. In the past 7 days, I was sleepy during the daytime…___ Never
___ Rarely
___ Sometimes
___ Often
___ Always

 

SOCIAL / EMOTIONAL SUPPORT

AWV checkmark.How often do you get the social and emotional support you need?___ Always
___ Often
___ Sometimes
___ Rarely
___ Never

 

STRESS

 Option A
Please circle the number (0-10) that best describes how much distress you have been experiencing in the past week including today.

___ 0 No distress
___ 1
___ 2
___ 3
___ 4
___ 5
___ 6
___ 7
___ 8
___ 9
___ 10 Extreme distress
 Option B
How often is stress a problem for you in handling such things as:
Your health? Your finances? Your family or social relationships? Your work?

___ Never or rarely
___ Sometimes
___ Often
___ Always

 

SUBSTANCE USE

 How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?___ 0
___ 1
___ 2
___ 3 or more times

 

TOBACCO USE

AWV checkmark.Option A
In the last 30 days, have you used tobacco?

a. Smoked cigarettes:



___ No
___ Yes
 b. Used a smokeless tobacco product:___ No
___ Yes
AWV checkmark.Option B
Have you smoked one or more cigarettes in the past month?

___ No
___ Yes
Current as of September 2013
Internet Citation: Health Assessments in Primary Care: A How-to Guide: Appendix 4: Adult Health Assessment Sample Questions. September 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/health-assessments/health-assessment-ap4.html