Medicare Health Risk Assessment (HRA)

Patient Name: DOB: Today’s Date

Physical Activity/Exercise

How many days a week do you usually exercise?

__________days per week c Light (stretching or slow walking) c Very heavy (running or stair climbing)

How intense is your typical exercise?

Smoking Status c Moderate (brisk walking) amount of time spent exercising c I am currently not exercising c Current smoker

Do you currently smoke cigarettes or use other types of tobacco?

Alcohol Use c Former smoker c Never a smoker c Heavy (jogging or swimming) c No alcohol use c Social drinker c Moderate (Men: 2 per day or less; Women: 1 per day or less) c Alcohol use (3 or more per day)

In a typical week, how often do you have 1 or more alcoholic drinks on one occasion?

Nutrition

Do you eat fiber, fruits and vegetables?

Oral Health

Do you see a dentist yearly?

Hearing

Do you have difficulty hearing when someone speaks in a whisper?

Do you have hearing problems when in a crowd?

Does a hearing problem cause you to argue with family members?

Sleep

How many hours of sleep do you get each night?

Activities of Daily Living

c Yes c No c Yes c No c Yes c No c Yes c No c Yes c No

Do you feel that you need assistance with dressing, feeding or bathing? c Yes c No

Do you have feelings of unsteadiness including balance? c Yes c No

Over the past year you have: c Not experienced a fall c Had one fall with injury c Had two or more falls c Yes c No c Yes c No c Yes c No

Do you need assistance with shopping, food preparation, housekeeping, laundry or transportation?

Do you need help with your medications?

Do you need assistance with handling financial affairs?

Motor Vehicle Safety

Do you wear a seatbelt every time you are in an automobile? c Yes c No

Sun Exposure

When outdoors, do you wear sunscreen? c Yes c No

Home Safety

Do you have working smoke and fire detectors in your home? c Yes c No

High Stress

How well do you handle the stress in your life?

c I’m usually able to cope effectively. c At times I have problems coping. c I often have problems coping.

How often is stress a problem for you?

c Never/Rarely c Sometimes c Often c Always

General Well-being

In general, how would you describe your health?

Depression c Excellent c Very good c Good c Fair c Poor c Not at all c Several days c More than half the days c Nearly every day c Not at all c Several days c More than half the days c Nearly every day c Yes c No c Very satisfied c Satisfied

Over the past 2 weeks how often, have you experienced loss of pleasure from your usual activities?

Over the past 2 weeks how often have you been bothered by feelings of sadness, depression or helplessness?

Have your feelings caused you distress or interfered with your ability to interact socially with friends?

Generally, how satisfied are you with your life?

Social/Emotional Support

c Dissatisfied c Very dissatisfied c Always c Usually c Sometimes c Rarely c Never

How often do you get the social and emotional support you need?