Back

Adult Wellness Questionnaire

Hospitalizations(Required)
Have you been hospitalized in the last year?
Osteoporosis Risk Assessment(Required)
Do you have any of these risk factors for osteoporosis? Select all that apply.
HIV Risk Assessment(Required)
Do you have any of these risk factors for HIV? Select all that apply.

Drug and Alcohol Use

What is your smoking history?(Required)
What is your smokeless tobacco history?(Required)
What is your pipe/cigar smoking history?(Required)
How would you describe your alcohol use?(Required)

Diet and Physical Activity

How would you describe your current diet? Select all that apply.(Required)
How frequently do you excercise(Required)

Mood Screening

In the past several weeks, have you experienced difficulty in the following areas? Select all that apply.(Required)
In the past two weeks, have you felt down, depressed, or hopeless?(Required)
In the past two weeks, have you felt little interest or pleasure in doing things?(Required)

Cognition Screening

In the past two weeks, have you felt any of these symptoms of anxiety? Select all that apply.(Required)

Functional Ability/Safety

How would you describe your ability to hear? Select all that apply.(Required)
Do you use hearing aids?(Required)
Due to health problems, do you feel you need the help of another person in any of the following activities of daily living? Select all that apply.(Required)
How much help do you need with indicated activities of daily living?(Required)
Due to health problems, do you feel you need the help of another person in any of the following instrumental activities of daily living? Select all that apply.(Required)
How much help do you need with indicated instrumental activities of daily living?(Required)
In the past several weeks, has your physical and emotional health limited your social activities with family, friends, neighbors, or groups?(Required)
In the past several weeks, has your physical and emotional health limited your ability to drive?(Required)
Fall history(Required)
Does your home have any of these safety risk factors? Select all that apply.(Required)

Advanced Directive

Have you completed any of the following Advanced Directives? Select all that apply.(Required)
Would you like the opportunity to discuss your end of life decisions or Advanced Directives with your provider?(Required)

Additional Medical Providers & Medical Suppliers

Please list any additional medical providers that you currently see:
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable
Leave blank if not applicable

Contact Information

** Please provide your full legal name as it appears on your driver’s license and you Alberta Health Care number.
This field is for validation purposes and should be left unchanged.