Medicare Wellness Portfolio

About You

Patient Registration & Care Team

Patient Name

Date of Birth

Preferred Name

Phone

+1

Address

Email

Emergency Contact

Preferred Pharmacy

Preferred Hospital

Caregiver (if applicable)

My Care Team

Primary Care

Cardiology

Pulmonology

Endocrinology

Neurology

Psychiatric

Other

Communication Preferences

Phone Text Patient Portal Email

Let's Get to Know Your Health

Health Risk Assessment (RGMW-003)

1. Overall Health

How would you rate your overall health?

Excellent Very Good Good Fair Poor

What is your biggest health goal this year?

2. Your Daily Life

Exercise Frequency

Avg Minutes/Session

Hours of Sleep/Night

Daily Habits (check all that apply)

I usually wake up feeling rested I eat fruits and vegetables most days I drink enough water each day

3. Your Health Conditions

Other Conditions

Hospitalized in the last year Emergency room visit in the last year

4. Medications Concerns

I sometimes forget my medications I have difficulty paying for medications I am having medication side effects I need medication refills today

5. Staying Safe

I have fallen in the last year I worry about falling I use a cane, walker, or wheelchair I have grab bars in my bathroom I have working smoke detectors

6. Emotional Wellness

I have been feeling down or depressed I have been feeling anxious or worried I have concerns about my memory I often feel lonely or isolated

7. Healthy Living

I currently smoke or use tobacco I drink alcohol I would like help with nutrition I would like help losing weight I would like to become more active

8. My Healthcare Team

Cardiologist

Pulmonologist

Neurologist

Endocrinologist

Psychiatrist

Eye Doctor

Dentist

Other

9. Final Questions

What concerns you most about your health?

What questions would you like to discuss with your provider today?

Your Medications

Medication Review & Reconciliation (RGMW-004)

Prescription Medications

Medication	Dose	How Often	Prescribing Provider	Refill?

Over-the-Counter Medications

Medication	Reason	How Often

Vitamins, Herbs & Supplements

Supplement	Dose	How Often

Medication Questions

I sometimes forget to take my medications I have trouble paying for my medications I have experienced medication side effects I use a pill organizer I would like to review my medications with my provider today

Medication Allergies