Annual Wellness Check-In Survey
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Annual Wellness Check-In Survey
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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.
What's included
- Self-reported general health and year-over-year change tracking
- Lifestyle habit assessment covering exercise, nutrition, and sleep
- Substance use screening for tobacco and alcohol
- Brief mental health mood and anxiety indicator questions
- Preventive screening and immunization compliance checklist
- Personal health goal setting and provider question capture
- Medical conditions checklist
- E-signature capture
- Structured medication list with dosage and frequency tracking
Who uses this template
- 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
All form fields
14 fields across 3 pages. Customize any field after signing up.
How to use the Annual Wellness Check-In Survey
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Annual Wellness Check-In Survey 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 Check-In Survey in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 14 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 Check-In Survey HIPAA compliant?
Yes. All Formisoft templates, including the Annual Wellness Check-In Survey, 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 14 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 Check-In Survey 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 Check-In Survey for your practice. Set up in minutes.
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