Annual wellness visit template
| Reason for visit Chief complaint Subjective narrative Review of systems “Please refer to patient-completed questionnaire (previsit template with checkboxes).” Past medical history (diagnoses and dates) Past surgical history Family history List of medications Socioeconomic history Substance use disorder assessment Occupational history Tobacco use Recent hospitalizations Objective Vital signs, weight, height, body mass index Physical examination Vision and hearing evaluation “Pertinent lab results and tests in the record were reviewed with the patient and a copy was provided to the patient as needed.” Assessment of any cognitive impairment General appearance Mood and affect Input from others Notes and plan | Depression screening (PRIME MD-PHQ2) Refresh note if PHQ-9 was completed Follow-up plan for depression Functional ability Does the patient exhibit a steady gait? How long did it take the patient to get up and walk from a sitting position? Is the patient self-reliant (can the patient do their own laundry, prepare meals, do household chores)? Does the patient handle his or her own medications? Does the patient handle his or her own money? Is the patient’s home safe (eg, good lighting, handrails on stairs and bath)? Did you notice or did patient express any hearing difficulties? Did you notice or did patient express any vision difficulties? Were distance and reading eye charts used? Notes and plan Advance care planning Was patient offered the opportunity to discuss advance care planning? If no, did you provide information on advance directives? Notes and plan Smoking cessation counseling Electrocardiogram results Required only in initial AWV Vaccines Screening recommendations Assessments and plan |