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Annual Wellness Check-In Survey

Asks about date of last annual visit, general health perception, and health changes since last visit. Built for primary care practices conducting structured annual wellness visits.

Questions
14
Pages
2
Time
about 4 min

Includes

  • E-signature
  • Medication list
  • Conditions checklist
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Your practice

Annual Wellness Check-In Survey

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • Primary care practices conducting structured annual wellness visits
  • Medicare wellness visit programs collecting pre-visit health data
  • Population health teams identifying preventive care gaps across panels
  • Family medicine clinics promoting proactive whole-person care planning

What's inside

Page 1 · Your information

  1. Date of Last Annual VisitDate
  2. General Health PerceptionMultiple Choice · 5 choices
  3. Health Changes Since Last VisitLong Text
  4. Exercise FrequencyMultiple Choice · 5 choices
  5. Nutrition Quality Self-RatingMultiple Choice · 5 choices

Page 2 · Additional details

  1. Mood & Anxiety ScreeningLong Text
  2. Preventive Screenings CompletedLong Text
  3. Immunizations Up to DateConditions
  4. Current MedicationsMedications
  5. Health Goals for Coming YearLong Text

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Annual Wellness Check-In Survey, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

Related templates

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 14 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Annual Wellness Check-In Survey for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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