Annual Wellness Check-In Survey

The Annual Wellness Check-In Survey provides a structured instrument for capturing a comprehensive snapshot of each patient's self-reported health status once per year. Aligned with the goals of the Medicare Annual Wellness Visit and preventive care best practices, this survey gathers information that clinical teams use to update care plans, identify emerging risk factors, and ensure patients are current on recommended screenings and immunizations. By collecting this data before the appointment, providers spend less time on routine questions and more time on meaningful clinical conversation.

The survey covers general health perception, changes in health status since the last visit, current exercise and nutrition habits, tobacco and alcohol use, sleep quality, and a brief mental health screening including mood and anxiety indicators. Patients report their compliance with recommended preventive services such as mammograms, colonoscopies, flu vaccines, and dental exams, enabling care teams to identify gaps and schedule overdue screenings. A health goals section invites patients to articulate what they want to focus on in the coming year, whether that is weight management, stress reduction, chronic disease management, or simply maintaining their current level of health.

This template is ideal for primary care practices, internal medicine groups, family medicine clinics, and Medicare wellness visit programs. Population health managers use the aggregated data to identify trends across their patient panel, prioritize outreach for patients with unmet preventive care needs, and measure the effectiveness of wellness initiatives year over year. By making the annual check-in a routine part of the patient relationship, practices demonstrate a commitment to proactive, whole-person care.