Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Annual Wellness Visit Form
Your information
Patient Name *
Date of Birth
____ / ____ / ________
Email Address
Phone Number
Current Medications
| Medication | Dose | How often |
|---|---|---|
Allergies
| Allergy | Reaction |
|---|---|
Medical Conditions
Family Medical History
Additional details
Preventive Screenings Completed
Immunization Status
Lifestyle Assessment
Have you noticed any changes in your mood?
Fall Risk Assessment
Advance Directive Status
Patient Signature
Date
Annual Wellness Visit Form template from formisoft.com. formisoft.com/intake-templates/annual-wellness