brevaCreate account

Medicare Annual Wellness Visit health risk assessment

Updated October 22, 2026. A free form your patients can fill in before the Medicare Annual Wellness Visit. It covers every topic Medicare requires and takes about 15 minutes. Print it, hand it out at check-in, or mail it with the appointment reminder.

What Medicare requires the assessment to cover

Under 42 CFR 410.15, the health risk assessment is self-reported, can be completed by the patient alone or with staff, takes no more than 20 minutes, is tailored to patients with limited English or limited health literacy, and addresses at least:

  • Demographic data, such as age, gender, race and ethnicity
  • How the patient rates their own health, frailty and physical functioning
  • Psychosocial risks, such as depression and life satisfaction, stress, anger, loneliness, pain and fatigue
  • Behavioral risks, such as tobacco, physical activity, nutrition and oral health, alcohol, sexual health, seat belt use and home safety
  • Activities of daily living: dressing, feeding, toileting, grooming, walking (including balance and fall risk) and bathing
  • Instrumental activities of daily living: shopping, preparing food, using the telephone, housekeeping, laundry, transportation, managing medications and handling money

Each topic above has its own section on this form. It is written in plain English; offer help reading it, or an interpreter, to any patient who needs one. The clinician reviews the answers during the visit and uses them for the personalized prevention plan. See the prevention plan checklist for what the note must show.

Related

Note templates for the visit itself: initial Annual Wellness Visit and subsequent Annual Wellness Visit. Coding: G0438 vs G0439 and the Annual Wellness Visit coding reference.

Page 1 of 5 of the printable formPage 2 of 5 of the printable formPage 3 of 5 of the printable formPage 4 of 5 of the printable formPage 5 of 5 of the printable form
Download the printable PDF

The questions on the form

About you

  1. Name
  2. Date of birth
  3. Today's date
  4. Gender
  5. Race and ethnicity, in your own words
  6. Preferred language
  7. Who filled in this form?I did / Someone helped me / Someone filled it in for me

Your health

  1. In general, how would you rate your health?Excellent / Very good / Good / Fair / Poor
  2. Compared with a year ago, your health isBetter / About the same / Worse
  3. In the past year, how many times have you stayed overnight in a hospital?None / Once / Two or more times
  4. Do you feel you have become weaker, slower or more tired over the past year?No / A little / A lot
  5. Can you walk a quarter of a mile (about two blocks) without stopping?Yes, easily / Yes, with difficulty / No
  6. Can you climb a flight of stairs without resting?Yes, easily / Yes, with difficulty / No

How you have been feeling

Over the past two weeks:

  1. How often have you felt down, depressed or hopeless?Not at all / Several days / More than half the days / Nearly every day
  2. How often have you had little interest or pleasure in doing things?Not at all / Several days / More than half the days / Nearly every day
  3. How often have you felt stressed, worried or on edge?Not at all / Several days / More than half the days / Nearly every day
  4. How often have you felt angry or irritable?Not at all / Several days / More than half the days / Nearly every day
  5. How often have you felt lonely or cut off from other people?Not at all / Several days / More than half the days / Nearly every day
  6. How much has pain gotten in the way of your daily life?Not at all / A little / Quite a bit / A lot
  7. How often have you felt too tired to do what you want to do?Not at all / Several days / More than half the days / Nearly every day

Your life

  1. Overall, how satisfied are you with your life?Very satisfied / Satisfied / Not very satisfied / Not at all satisfied

Your habits and safety

  1. Do you smoke or use tobacco or nicotine products, including e-cigarettes?Never / I used to / Yes, now
  2. How many days a week do you drink alcohol?None / 1 or 2 / 3 to 5 / 6 or 7
  3. On a day you drink, how many drinks do you usually have?I don't drink / 1 / 2 / 3 or 4 / 5 or more
  4. How many days a week are you physically active for at least 30 minutes (walking, gardening, exercise)?None / 1 or 2 / 3 or 4 / 5 or more
  5. How many servings of fruit and vegetables do you eat on a typical day? (A serving is about a handful.)None / 1 or 2 / 3 or 4 / 5 or more
  6. Do you have trouble chewing or swallowing, or pain in your mouth or teeth?No / Yes
  7. When did you last see a dentist?Within a year / 1 to 2 years ago / More than 2 years ago
  8. Do you have any questions or concerns about your sexual health?No / Yes / Prefer not to say
  9. Do you always wear a seat belt in a car?Yes / No
  10. Do you drive?Yes / No
  11. Have you fallen in the past year?No / Once / Two or more times
  12. Are you afraid of falling?No / Yes
  13. Do you have trouble with your balance or feel unsteady when you walk?No / Sometimes / Often
  14. Do you have working smoke detectors at home?Yes / No / Not sure
  15. At home, are your rugs, stairs and lighting safe to walk on?Yes / No / Not sure
  16. Do you feel safe where you live?Yes / No

Everyday activities

Can you do these on your own?

  1. Get dressedWithout help / With some help / Cannot do
  2. EatWithout help / With some help / Cannot do
  3. Use the toiletWithout help / With some help / Cannot do
  4. Groom yourself (brush teeth, comb hair)Without help / With some help / Cannot do
  5. Bathe or showerWithout help / With some help / Cannot do
  6. Walk across a roomWithout help / With some help / Cannot do
  7. Get in and out of a bed or chairWithout help / With some help / Cannot do

Running your home

Can you do these on your own?

  1. Shop for groceries and other things you needWithout help / With some help / Cannot do
  2. Prepare your own mealsWithout help / With some help / Cannot do
  3. Use the telephoneWithout help / With some help / Cannot do
  4. Do houseworkWithout help / With some help / Cannot do
  5. Do laundryWithout help / With some help / Cannot do
  6. Get to places beyond walking distanceWithout help / With some help / Cannot do
  7. Take your medicines correctly and on timeWithout help / With some help / Cannot do
  8. Manage your money and pay billsWithout help / With some help / Cannot do
  9. How do you usually get to appointments?I drive / Someone drives me / Public transport / Other

Anything else

  1. Do you have trouble hearing, even with hearing aids?No / Yes
  2. Have you or anyone close to you noticed changes in your memory or thinking?No / Yes / Not sure
  3. What would you most like to talk about at your visit?

See it with your workflow.

Create account