Annual Wellness Questions

An easy to use questionnaire that allows healthcare professionals understand an individual’s impact of current health on daily activities as part of disease prevention and detection strategies.

1. Please list all doctors that you have seen in the past year and the specialty
2. Please list all any medications you are currently taking
3. Please list any tests you have done in the past year such as blood tests, colonoscopy, mammograms, CT Scan, MRI, etc.
4. Have you had any recent immunizations?
5. Do you have a living will or advance directive?
6. Can you get places out of walking distance without help?For example, can you travel alone by bus, taxi, or drive your own car?
7. Can you shop for groceries or clothes without help?
8. Can you prepare your own meals?
9. Can you do your own housework without help?
10. Can you handle your own money without help?
11. Do you need help eating, bathing, dressing, or getting around your home?
12. Have you been given any information to help you keep track of your medications?
13. Have you been given any information to help you identify hazards in your house that might hurt you?
14. Have you fallen two (2) or more times in the past year?
15. How often in the past 4 weeks, have you had problems using the telephone?
16. How often in the past 4 weeks, have you had trouble eating well?
17. How often in the past 4 weeks, have you been bothered by your teeth or dentures?
18. During the past 4 weeks, was someone available to help you if you needed and wanted help?For example, if you felt very nervous, lonely or blue, got sick and had to stay in bed, needed someone to talk to, needed help with daily chores, or needed help just taking care of yourself.
19. Are you having difficulties driving your car?
20. How confident are you that you can control and manage most of your health problems?
21. How often do you have trouble taking medicines the way you have been told to take them?
22. Do any family members have a personal history with any health issues, please list below
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Steps on how to print your input & results:

1. Fill in the calculator/tool with your values and/or your answer choices and press Calculate.

2. Then you can click on the Print button to open a PDF in a separate window with the inputs and results. You can further save the PDF or print it.

Please note that once you have closed the PDF you need to click on the Calculate button before you try opening it again, otherwise the input and/or results may not appear in the pdf.

The Annual Wellness Questionnaire consists of 22 items and collects data regarding:

  • Current health care providers;
  • Current medication;
  • Immunisations and tests during the past year;
  • End of life planning;
  • Functional ability in activities of daily living;
  • Access to help if required;
  • History of health issues within family.

Specialty: Preventive Medicine

Abbreviation: AWV