Annual Wellness Visit Form
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The Annual Wellness Visit Form streamlines the pre-visit process for annual physicals and preventive wellness exams. Rather than repeating the entire intake questionnaire each year, this focused form captures what has changed: new diagnoses or health events, medication changes, new allergies, updated family history, and changes in social habits.
The preventive care section lists age and gender-appropriate screenings (mammograms, colonoscopies, bone density, prostate screening) and prompts patients to indicate their last screening date. This helps providers identify gaps in preventive care and address them during the wellness visit. Vaccination tracking covers flu, COVID, shingles, pneumonia, and other recommended immunizations.
Health goals and concerns give patients a voice in setting the agenda for their annual visit. Common goals include weight management, exercise, stress reduction, smoking cessation, and chronic disease management. This template can be sent to patients 3-5 days before their appointment, ensuring the visit is productive and focused from the start.
What's included
- Patient demographics and contact information
- Structured medication list with dosage and frequency tracking
- Allergy documentation with severity levels
- Medical conditions checklist
- Family medical history with hereditary condition tracking
- Age-appropriate preventive screening checklist (mammogram, colonoscopy, bone density, prostate)
- Immunization status for flu, COVID, shingles, pneumonia, and Tdap
- Lifestyle assessment covering exercise, diet, alcohol, and tobacco use
- Depression screening (PHQ-2) questionnaire
- Fall risk assessment for older adults
- Advance directive and healthcare proxy documentation
- Patient e-signature capture
Who uses this template
- Primary care annual physical exams
- Medicare Annual Wellness Visit (AWV)
- Preventive health check-ups
- Employee annual health assessments
All form fields
15 fields across 3 pages. Customize any field after signing up.
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