Medicare Annual Wellness Visit, initial
Preventive care

Blank documentation outlines. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

BEFORE THE VISIT
Eligibility and prior wellness visits checked, with source and date: [ ]
Health risk assessment completed, by whom and date: [ ]

HISTORY
Medical and surgical history: [ ]
Family history: [ ]
Current medications and supplements: [ ]
Current opioid prescriptions reviewed: [ ]
Substance use screening tool and result: [ ]
Current providers and suppliers involved in care: [ ]

MEASUREMENTS
Height, weight, body mass index and blood pressure, with units: [ ]
Other measurements taken: [ ]

SCREENING AND SAFETY
Cognitive assessment method and findings: [ ]
Depression screening tool and result: [ ]
Hearing, daily activities, fall risk and home safety findings: [ ]

PREVENTION PLAN
Written screening schedule for the next 5 to 10 years: [ ]
Risk factors and conditions, with interventions recommended or underway: [ ]
Personalized health advice and referrals: [ ]

OPTIONAL ELEMENTS
Advance care planning discussed, if the patient agreed: [ ]
Physical activity and nutrition assessment tool and result, if performed: [ ]

OTHER CARE TODAY
Problems addressed separately today, if any: [ ]

FOLLOW-UP
Follow-up timing and purpose: [ ]
Return precautions discussed: [ ]
Patient questions and understanding: [ ]