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Appendix 4: Adult Health Assessment Sample Questions
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Table of Contents
- Health Assessments in Primary Care
- Introduction
- Section 1. How Ready is Your Practice to Implement a New Health Assessment?
- Section 2. How Does Your Practice Choose an Assessment?
- Section 3. How Do You Work Health Assessments into Your Office Workflow?
- Section 4. How Do You Use the Health Assessment Information You Collect?
- Section 5. How Do You Activate and Engage Patients in Using Their Health Assessment Information?
- Section 6. How Does Your Practice Sustain Health Assessments?
- Appendixes
- Appendix 1: Background on Health Assessments in Primary Care
- Appendix 2: Health Assessment Case Study
- Appendix 3: Health Assessments for Adults
- Appendix 4: Adult Health Assessment Sample Questions
- Appendix 5: Assessments for Children
- Appendix 6: Assessments for Adolescents
- Appendix 7: Health Assessments for Seniors
- Appendix 8: Crosswalk of Health Assessments Related to Incentive and Quality Programs
- Appendix 9: Tools for Making Changes in Your Practice
- Appendix 10: Health Assessment Information for Patients
- Appendix 11: Patient Feedback Survey Example
- References
See Also
Diabetes and the Insulin PumpThis 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 |
| 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 |
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
| Option A a. On how many of the last 7 days did you engage in moderate to strenuous exercise (like a brisk walk)? | ___ 7 ___ 6 ___ 5 ___ 4 days ___ 3 ___ 2 ___ 1 ___ 0 |
| On those days that you engage in moderate to strenuous exercise, how many minutes, on average, do you exercise at this level? | ______ minutes | |
| Option B In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate? (This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job.) | ___ 7 ___ 6 ___ 5 ___ 4 days ___ 3 ___ 2 ___ 1 ___ 0 |
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 |
| b. Used a smokeless tobacco product: | ___ No ___ Yes | |
| Option B Have you smoked one or more cigarettes in the past month? | ___ No ___ Yes |
Publication: 13-0061-EF
Page last reviewed September 2013
Page originally created September 2013
Internet Citation: Appendix 4: Adult Health Assessment Sample Questions. Content last reviewed September 2013. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/ncepcr/tools/assessments/health-ap4.html
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