Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Annual Wellness Check-In Survey
Your information
Date of Last Annual Visit
____ / ____ / ________
General Health Perception
- Excellent
- Very good
- Good
- Fair
- Poor
Health Changes Since Last Visit
Exercise Frequency
- Never
- Less than once a week
- 1–2 days a week
- 3–4 days a week
- 5 or more days a week
Nutrition Quality Self-Rating
- Very good
- Good
- Fair
- Poor
- Not sure
Tobacco / Alcohol Use
Sleep Quality
- Very good
- Good
- Fair
- Poor
- Very poor
Additional details
Mood & Anxiety Screening
Preventive Screenings Completed
Immunizations Up to Date
Current Medications
| Medication | Dose | How often |
|---|---|---|
Health Goals for Coming Year
Questions for Your Provider
Patient Signature
Date
Annual Wellness Check-In Survey template from formisoft.com. formisoft.com/intake-templates/annual-wellness-check-in