Annual Wellness Visit Form
Form Preview
Annual Wellness Visit Form
Page 1 of 3
Sign up and start customizing in minutes.
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.
How to use the Annual Wellness Visit Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Annual Wellness Visit Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Annual Wellness Visit Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 15 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Annual Wellness Visit Form HIPAA compliant?
Yes. All Formisoft templates, including the Annual Wellness Visit Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 15 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Annual Wellness Visit Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Annual Wellness Visit Form for your practice. Set up in minutes.
Related templates
Annual Wellness Check-In Survey
Yearly wellness survey capturing patients' self-reported health status, lifestyle habits, preventive care compliance, mental health screening, and health goals. Supports proactive care planning and population health management.
Vaccination Consent Form
A consent form for vaccine administration that captures patient screening questions, vaccine information acknowledgment, and authorization to immunize.
Immunization History Form
Comprehensive immunization record capturing childhood and adult vaccinations, booster schedules, adverse reactions, and exemption documentation. Essential for preventive care and compliance tracking.