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 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

	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
	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
	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

	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

	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

	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

	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

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

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

	Option A In the last 30 days, have you used tobacco? a. Smoked cigarettes:	___ No ___ Yes
	b. Used a smokeless tobacco product:	___ No ___ Yes
	Option B Have you smoked one or more cigarettes in the past month?	___ No ___ Yes

Internet Citation: Appendix 4: Adult Health Assessment Sample Questions. Content last reviewed 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

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