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EPM Tools - Patient-Centered Medical Home Annual Questionnaires
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As part of SETMA’s Patient-Centered Medical Home, we annually complete five questionnaires for each patient seen to assess the following:

  • Fall Risk
  • Pain Assessment
  • Functional Assessment
  • Wellness
  • Stress

The standard is that each should be completed on all patients at least once a year and more frequently if a change in conditions dictates.  The Fall Risk should be completed on all patients over 50 and on younger patients who as a result of chronic condition are at risk of falling.
Provider performance on these questionnaires is publicly reported below. The content of the questions are as follows:

Once the Fall Risk Assessment is completed, the provider should, on the basis of the score, access the “Guidelines for Fall Precaution” and prepare a plan for preventing falls.

Source -- Global Assessment of Functioning (GAF) Scale --  American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). doi:10.1176/appi.books.9780890423349.

(Source:  NIH. (2007). National Institutes of Health.  Pain Intensity Scales Retrieved January 17, 2007NIH. (2007). National Institutes of Health. Pain Intensity Scales  Retrieved January 17, 2007

The Stress Assessment based on the Score

>=80 points

You have an excellent resistance to stress.

>=60 points

You may be somewhat vulnerable to stress.

<60 points

You may be seriously vulnerable to stress.

(Source: University of California, Berkley Wellness Letter, August 1995.  Scale Developers: Lyle Miller and Alma Dell Smith of Boston University Medical Center)

Wellness Assessment results based on the Score

< 5 points


5-9 points


10-19 points


20-29 points

Very good

>=30 points


(Source:   University of Wisconsin, Health Promotion and Human Development Department.  Developers: Anne Abbott, Jane P. Jones and John Munson)

2929 Calder
3570 College
Mark A. Wilson Clinic
2010 Dowlen
2400 Highway 365
610 Strickland Drive
137 N LHS Drive

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