Questionnaire

▼ FIVE YEAR ROAD MAP - QUESTIONNAIRE...

► MEDICARE MEMBER INFORMATION...
Date*
Date Format: MM slash DD slash YYYY
Member Name*
Part A Coverage Start Date*
Date Format: MM slash DD slash YYYY
Part B Coverage Start Date*
Date Format: MM slash DD slash YYYY
Gender*
- Male
- Female
Phone*
Email*
► 1. ONE TIME "WELCOME TO MEDICARE" PREVENTIVE VISIT EXAM...
Medicare covers a one-time preventive visit within the first 12 months that you have medicare part b (medical insurance).
Have You Had Your Welcome To Medicare Exam?*
- Yes
- No
If Yes, Date*
Date Format: MM slash DD slash YYYY
► 2. YEARLY WELLNESS VISIT...
If you’ve had medicare part b (medical insurance) for longer than 12 months, you can get a yearly “wellness” visit.
Have You Had Your Medicare Yearly Wellness Visit Exam Taken?*
- Yes
- No
If Yes, Date*
Date Format: MM slash DD slash YYYY
► 3. ABDOMINAL AORTIC ANEURISM SCREENING...
How often is covered? medicare covers this screening once in your lifetime if you get a referral.
Have You Ever Had An Abdominal Aortic Aneurysm Screening Done?*
- Yes
- No
If Yes, Date*
Date Format: MM slash DD slash YYYY
Are you at risk for Abdominal Aortic Aneurism? Answer the following questions:
Do You Have A Family History Of Abdominal Aortic Aneurism?*
- Yes
- No
Is Your Age Between 65-75 And Have You Smoked More Than 100 Cigarettes In Your Life?*
- Yes
- No
► 4. ALCOHOL MISUSE SCREENING AND COUNSELING...
How often is covered? medicare covers one alcohol misuse screening per year. if your primary care doctor or other primary care practitioner determines you’re misusing alcohol, you can get up to 4 brief face-to-face counseling sessions per year.
Are You An Adult With Medicare (Including Pregnant Women) Who Use Alcohol, But Don’t Meet The Medical Criteria For Alcohol Dependency?*
- Yes
- No
► 5. BONE MASS MEASUREMENT...
How often is it covered? once every 24 months (more often if medically necessary).
Have You Ever Had A Bone Mass Measurement Test Done?*
- Yes
- No
If Yes, Date*
Date Format: MM slash DD slash YYYY
Are you at risk for osteoporosis? Answer the following questions:
Have You Had Any Vertebral Abnormalities, As Demonstrated By An X-Ray?*
- Yes
- No
Have You Received Steroid Treatments?*
- Yes
- No
Have You Ever Been Diagnosed With Hyperparathyroidism?*
- Yes
- No
Have You Ever Taken Or Are You Presently Taking Any Osteoporosis Medication?*
- Yes
- No
(Only For Female) Has Your Doctor Ever Mention To You That You Are Estrogen-Deficient And That You Might Be At Risk For Osteoporosis?*
- Yes
- No
► 6. BREAST CANCER SCREENING (MAMMOGRAMS)...
How often is it covered? once every 12 months.
Have You Ever Had A Breast Cancer Screening?*
- Yes
- No
If Yes, Date*
Date Format: MM slash DD slash YYYY
Are you at high risk for Brest Cancer? Answer the following questions:
Are You Over The Age Of 40?*
- Yes
- No
Have You Had Breast Cancer In The Past?*
- Yes
- No
Do You Have A Family History Of Breast Cancer (Like Mother, Sister, Daughter, Or Two Or More Close Relatives Who Have Had Breast Cancer)?*
- Yes
- No
Did You Have Your First Baby After The Age Of 30?*
- Yes
- No
Have You Ever Had A Baby?*
- Yes
- No
► 7. CARDIOVASCULAR DISEASE (BEHAVIORAL THERAPY)...
How often is it covered? once every 12 months.
Have You Consulted Your Doctor Regarding Encouraging Aspirin Use When Benefits Outweigh Risks?*
- Yes
- No
Have You Been Tested For High Blood Pressure?*
- Yes
- No
Have You Received Counseling Regarding The Promotion Of A Healthy Diet?*
- Yes
- No
► 8. CARDIOVASCULAR DISEASE SCREENING...
How often is it covered? once every 60 months.
Have You Had A Test For Cholesterol, Lipid And Triglyceride Levels Done?*
- Yes
- No
If Yes, Date*
Date Format: MM slash DD slash YYYY
► 9. CERVICAL AND VAGINAL CANCER SCREENING...
How often is it covered? medicare covers these screening tests once every 24 months, or once every 12 months if you’re at high risk for cervical or vaginal cancer, or if you’re of child-bearing age and had an abnormal pap test in the past 36 months.
Have You Ever Had A Cervical And Vaginal Cancer Screening?*
- Yes
- No
If Yes, Date*
Date Format: MM slash DD slash YYYY
Are you at high risk for cervical cancer? Answer the following questions:
Have You Had An Abnormal Pap Test?*
- Yes
- No
Have You Had Cervical Or Vaginal Cancer In The Past?*
- Yes
- No
Have You Had A History Of Sexually Transmitted Disease (Including HIV Infection)?*
- Yes
- No
Did You Begin Having Sex Before Age 16?*
- Yes
- No
Have You Had Many Sexual Partners?*
- Yes
- No
Do You Know If Your Mother Took Des (Diethylstilbestrol), A Hormonal Drug, When She Was Pregnant With You?*
- Yes
- No
► 10. COLORECTAL CANCER SCREENING...
How often is it covered? • multi-target stool dna test—once every 3 years for people who meet all of these conditions: ––they’re between 50–85. ––they show no signs or symptoms of colorectal disease including, but not limited to, lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, or fecal immunochemical test. ––they’re at average risk for developing colorectal cancer, meaning they have no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including crohn’s disease and ulcerative colitis. ––they have no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer. Have you ever had the following exams done?
Fecal Ocult Blood Test*
- Yes
- No
Flexible Sigmoidoscopy*
- Yes
- No
Colonoscopy*
- Yes
- No
Barium Enema*
- Yes
- No
Are you at risk of colorectal cancer? Answer the following questions:
Have You Had Colorectal Cancer Before, Even If It Has Been Completely Removed?*
- Yes
- No
Do You Have A Close Relative, (Brother, Sister, Parent Or Child), Who Had Colorectal Polyps Or Colorectal Cancer?*
- Yes
- No
Do You Have A History Of Polyps?*
- Yes
- No
Do You Presently Have Any Inflammatory Bowel Disease, Like Ulcerative Colitis Or Chrohn’s Disease?*
- Yes
- No
► 11. DEPRESSION SCREENING...
How often is it covered? medicare covers one depression screening per year.
Have You Visited Your Doctor For Depression Screening?*
- Yes
- No
If Yes, Date*
Date Format: MM slash DD slash YYYY
► 12. DIABETES...
How often is it covered? based on the results of your screening tests, you may be eligible for up to 2 diabetes screenings per year.
Have You Ever Had A Diabetes Screening Done?*
- Yes
- No
If Yes, Date*
Date Format: MM slash DD slash YYYY
Have You Been Diagnosed With Diabetes?*
- Yes
- No
Do You Have High Blood Pressure, Dyslipidemia (History Of Abnormal Cholesterol And Triglyceride Levels), Obesity, Or History Of High Blood Sugar (Glucose)?*
- Yes
- No
Are You Overweight, Or Do You Have A Family History Of Diabetes (Parents, Brothers, Or Sisters)?*
- Yes
- No
(Female Only) Do You Have A History Of Gestational Diabetes (Diabetes During Pregnancy), Or Had You Had A Baby Weighing Over 9 Pounds?*
- Yes
- No
► 13. GLAUCOMA TEST...
How often is it covered? once every 12 months.
Have You Ever Had A Glaucoma Test Done?*
- Yes
- No
If Yes, Date*
Date Format: MM slash DD slash YYYY
Are you at high risk for Glaucoma? Answer the following:
Do You Have Diabetes?*
- Yes
- No
Do You Have A Family History Of Glaucoma?*
- Yes
- No
Are You African American And Age 50 Or Older?*
- Yes
- No
Are You Hispanic And Age 65 And Older?*
- Yes
- No
► 14. HEPATITIS B VIRUS (HBV) INFECTION SCREENING...
How often is it covered? hbv infection screenings are covered: • annually only for those with continued high risk who don’t get a hepatitis b vaccination. • for pregnant women: ––at the first prenatal visit for each pregnancy. ––at the time of delivery for those with new or continued risk factors. ––at the first prenatal visit for future pregnancies, even if you previously got the hepatitis b shot or had negative hbv screening results.
Are You At High Risk For HBV Infection?*
- Yes
- No
Are You Pregnant?*
- Yes
- No
► 15. HEPATITIS C SCREENING TEST...
How often is it covered? medicare covers a one-time hepatitis c screening test. medicare also covers a repeat screening yearly for certain people at high risk.
Do You Have A Current Or Past History Of Illicit Injection Drug Use?*
- Yes
- No
Have You Had A Blood Transfusion Before 1992?*
- Yes
- No
Were You Born Between 1945-1965?*
- Yes
- No
► 16. HIV SCREENING...
How often is it covered? medicare covers this test once every 12 months, or up to 3 times during a pregnancy.
Are You 15-65, Not At Risk And Ask For The Screening?*
- Yes
- No
Are You Younger Than 15 Or Older Than 65, At An Increased Risk For The Virus, And Ask For The Screening?*
- Yes
- No
► 17. LUNG CANCER SCREENING...
How often is it covered? once every 12 months.
Are You 55-77 Year Old?*
- Yes
- No
Are You Asymptomatic (You Don’t Have Signs Or Symptoms Of Lung Cancer)?*
- Yes
- No
Are You Either A Current Smoker Or Have Quit Smoking Within The Last 15 Years?*
- Yes
- No
Do You Have A Tobacco Smoking History Of At Least 30 “Pack Years” (An Average Of One Pack A Day For 30 Years)?*
- Yes
- No
► 18. MEDICAL NUTRITION THERAPY...
How often is it covered? medicare covers 3 hours of one-on-one counseling services the first year, and 2 hours each year after that. if your condition, treatment, or diagnosis changes, you may be able to get more hours of treatment with a doctor’s referral.
Have You Ever Received Medical Nutrition Therapy?*
- Yes
- No
Do You Presently Have Renal Disease (People With Kidney Disease, But Not On Dialysis)?*
- Yes
- No
Have You Had A Kidney Transplant Within The Last Three Years?*
- Yes
- No
► 19. MEDICARE DIABETES PREVENTION PROGRAM...
How often is it covered? the program begins with 16 core sessions offered in a group setting over a 6-month period. once you complete the core sessions, you’ll get 6 more months of less intensive monthly follow-up sessions to help you maintain healthy habits. you’ll also get an additional 12 months of ongoing maintenance sessions if you meet certain weight loss and attendance goals.
Do You Have Medicare Part B?*
- Yes
- No
Have You Had A Hemoglobin A1C Test Result Between 5.7 And 6.4%, A Fasting Plasma Glucose Of 110-125Mg/Dl, Or A 2-Hour Plasma Glucose Of 140-199 Mg/Dl (Oral Glucose Tolerant Test) Within 12 Months Of Attending The First Core Session?*
- Yes
- No
Do You Have A Body Mass Index (Bmi) Of 25 Or More (Bmi Of 23 Or More If You’re Asian)?*
- Yes
- No
Have You Ever Been Diagnosed With Type 1 Or Type 2 Diabetes Or End-Stage Renal Disease (ESRD)?*
- Yes
- No
Have You Ever Participated In The Medicare Diabetes Prevention Program?*
- Yes
- No
► 20. OBESITY SCREENING AND COUNSELING...
How often is it covered? medicare covers behavioral therapy sessions to help you lose weight.
Is You Current BMI 30 Or More?*
- Yes
- No
► 21. PROSTATE CANCER SCREENING...
How often is it covered? • digital rectal examination—once every 12 months. • psa test—once every 12 months.
Have You Ever Had A Prostate Cancer Screening, Including Digital Rectal Examination And PSA Test?*
- Yes
- No
Are You Over 50?*
- Yes
- No
Do You Have A Father, Brother Or Son Who Has Had Prostate Cancer, Especially If Your Relatives Were Young When They Got The Disease?*
- Yes
- No
Are You African American?*
- Yes
- No
Do You Eat A Lot Of Read Met Or High Fat Dairy Products?*
- Yes
- No
► 22. SEXUALLY TRANSMITTED INFECTION SCREENINGS AND COUNSELING?
How often is covered? medicare covers these tests once every 12 months or at certain times during pregnancy. medicare also covers up to 2 individual 20 to 30 minute, face-to-face, high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for stis.
Have You Been Diagnose With Chlamydia, Gonorrhea, Syphilis, And/Or Hepatitis B?*
- Yes
- No
► 23. SHOTS – FLU...
How often is it covered? once each flu season. Are You Under 65 With Any One Of The Following Conditions?
Heart Disease?*
- Yes
- No
Lung Disease?*
- Yes
- No
Diabetes?*
- Yes
- No
End Stage Renal Disease?*
- Yes
- No
► 24. SHOTS - PNEUMOCOCCAL...
How often is covered? most people only need one shot once in their lifetime. a different, second shot, is covered 11 months after you get the first shot.
Are You Interested On Getting A Pneumococcal Shot?*
- Yes
- No
► 25. SHOTS – HEPATITIS B...
How often is it covered? once each flu season. Are You At Medium Or High Risk For Hepatitis B? Have You Been Diagnosed With:
Hemophilia?*
- Yes
- No
End Stage Renal Disease?*
- Yes
- No
Do You Live With Someone Who Has Hepatitis B?*
- Yes
- No
Are You A Healthcare Worker In Contact With Blood Or Body Fluids?*
- Yes
- No
► 26. TOBACCO USE CESSATION COUNSELING...
How often is it covered? medicare will cover up to 8 face-to-face visits during a 12-month period.
Have You Ever Had Tobacco Use Cessation Counseling?*
- Yes
- No
Do You Smoke?*
- Yes
- No

This website was current at the time it was published or uploaded onto the web. Medicare policy changes frequently. Our website was prepared as a service to the public and is not intended to grant rights or impose obligations, it contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

▼ FIVE YEAR ROAD MAP - QUESTIONNAIRE...

► MEDICARE MEMBER INFORMATION...

► 1. ONE TIME "WELCOME TO MEDICARE" PREVENTIVE VISIT EXAM...

► 2. YEARLY WELLNESS VISIT...

► 3. ABDOMINAL AORTIC ANEURISM SCREENING...

Are you at risk for Abdominal Aortic Aneurism? Answer the following questions:

► 4. ALCOHOL MISUSE SCREENING AND COUNSELING...

► 5. BONE MASS MEASUREMENT...

Are you at risk for osteoporosis? Answer the following questions:

► 6. BREAST CANCER SCREENING (MAMMOGRAMS)...

Are you at high risk for Brest Cancer? Answer the following questions:

► 7. CARDIOVASCULAR DISEASE (BEHAVIORAL THERAPY)...

► 8. CARDIOVASCULAR DISEASE SCREENING...

► 9. CERVICAL AND VAGINAL CANCER SCREENING...

Are you at high risk for cervical cancer? Answer the following questions:

► 10. COLORECTAL CANCER SCREENING...

Are you at risk of colorectal cancer? Answer the following questions:

► 11. DEPRESSION SCREENING...

► 12. DIABETES...

► 13. GLAUCOMA TEST...

Are you at high risk for Glaucoma? Answer the following:

► 14. HEPATITIS B VIRUS (HBV) INFECTION SCREENING...

► 15. HEPATITIS C SCREENING TEST...

► 16. HIV SCREENING...

► 17. LUNG CANCER SCREENING...

► 18. MEDICAL NUTRITION THERAPY...

► 19. MEDICARE DIABETES PREVENTION PROGRAM...

► 20. OBESITY SCREENING AND COUNSELING...

► 21. PROSTATE CANCER SCREENING...

► 22. SEXUALLY TRANSMITTED INFECTION SCREENINGS AND COUNSELING?

► 23. SHOTS – FLU...

► 24. SHOTS - PNEUMOCOCCAL...

► 25. SHOTS – HEPATITIS B...

► 26. TOBACCO USE CESSATION COUNSELING...