Follow the steps to complete the wellness checkup online.

1. Click ‘Get Form’ button to access the AGE 65+ (or MEDICARE) wellness checkup form. This will allow you to open the document in your preferred editing environment.
2. Begin by filling in your name, date of birth, and today’s date at the top of the form. Ensure that the information is accurate to avoid any issues.
3. Proceed to question 1, and circle the age range that applies to you: Under 65, 65-69, 70-79, or 80 or more.
4. In question 2, circle your gender as either Male or Female.
5. For question 3, indicate how much you have been bothered by emotional problems in the past four weeks by circling the most appropriate option.
6. Question 4 asks if your physical and emotional health has limited your social activities. Circle the option that best reflects your experience.
7. In question 5, describe the level of body pain you have experienced in the past four weeks by selecting the appropriate response.
8. Question 6 addresses whether you had someone available to help you if needed. Circle the answer that reflects your situation.
9. Question 7 pertains to evaluating the hardest physical activity you could perform for at least two minutes. Choose from the options provided.
10. Rate your overall health in question 8 by circling one of the responses provided.
11. For question 9, indicate how things have been going for you during the past four weeks by selecting the option that best represents your experience.
12. In question 10, identify if you are having difficulties driving your car with the relevant response.
13. For questions 11 and 12, answer whether you have fallen two or more times in the past year and if you are afraid of falling.
14. Question 13 inquires about your smoking status. Select the option that applies to you.
15. For question 14, circle how often you fasten your seat belt when in a car.
16. Question 15 addresses various problems you may have experienced in the past four weeks; select the most appropriate frequency for each.
17. In question 16, describe your eating habits by choosing the response that reflects how often you eat healthy foods.
18. Question 17 asks about your exercise routine; select the option that best describes your activity level.
19. For question 18, circle whether you have received information about home hazards and medication tracking.
20. Question 19 asks about difficulties in taking medications as prescribed; choose the appropriate response.
21. In question 20, evaluate your confidence in managing your health problems.
22. Question 21 addresses hearing difficulties; circle yes or no.
23. Choose your race in question 22 by circling all that apply.
24. In the suppliers section, list any Medicare-covered equipment and services.
25. For the functional assessment section, indicate your ability to perform daily tasks by circling whether you are Independent, Need some help, or Dependent.
26. Complete the alcohol and substance abuse screening by responding to the questions with a yes or no.
27. For the advanced directive section, indicate if you prepared a document and if you would like to schedule a review with your provider.
28. Finally, provide your signature and the date at the end of the form.
29. After completing the form, ensure all fields are filled out correctly, then save any changes, download, print, or share your completed wellness checkup.

Take the next step toward better health by completing the AGE 65+ (or MEDICARE) wellness checkup online today.