Annual Wellness Visit Questionnaire

A clinical intake form medical practices can hand out ahead of the annual wellness visit to gather a patient's health history, habits, and current symptoms.

Use this template

Full name

Nombre

Apellido

Date of birth

What is your history of alcohol use?

I never drink I drink occasionally I drink regularly I drink heavily or feel dependent on alcohol

Do you eat a balanced diet with minimal salt and unhealthy fats?

Yes No Sometimes

Have you had any unintentional weight loss in the past 6 months?

Yes No

What is your current smoking history?

Never smoked Former smoker Current smoker

If you smoke or used to smoke, for how many years?

What is your history of illegal drug use?

Never Occasionally Regularly Prefer not to say

Considering your age, how would you describe your overall health?

Excellent Good Fair Poor

How much difficulty do you have walking about 2-3 blocks (1/4 mile)?

None Some A lot Unable to do it

In the past 7 days, how many days did you exercise?

0 days 1-2 days 3-4 days 5-7 days

Have you visited the dentist in the past 12 months?

Yes No

Over the past two weeks, have you felt down, depressed, or hopeless?

Not at all Several days More than half the days Nearly every day

Over the past two weeks, have you felt little interest or pleasure in doing things?

Not at all Several days More than half the days Nearly every day

Do you always fasten your seatbelt when riding in a car?

Always Sometimes Never

Do you have any problems with your hearing?

Yes No

Have you seen an audiologist in the past 12 months?

Yes No

Do you have any problems with balance?

Yes No

Do you have any problems with walking?

Yes No

A fall is when your body reaches the ground without being pushed. Have you fallen in the past 12 months?

Yes No

If you answered yes, how many times have you fallen in the past 12 months?

In the past 7 days, did you need help with daily activities such as eating, dressing, grooming, bathing, walking, or using the toilet?

Yes No

In the past 7 days, did you need help with tasks such as laundry, shopping, using the phone, preparing food, or taking your medication?

Yes No

Have you noticed new or worsening weakness or tiredness in the last year?

Yes No

Have you had any recent changes in your vision?

Yes No

Have you seen an ophthalmologist in the past 12 months?

Yes No

Have you recently had trouble breathing?

Yes No

Do you have a persistent cough that won't go away?

Yes No

Do you ever have chest pain, tightness, or heaviness?

Yes No

Do you feel short of breath with daily activities such as dressing, bathing, or walking?

Yes No

Do you have difficulty breathing while lying down flat?

Yes No

Do your legs swell?

Yes No

Do you wake up at night feeling smothered or with tightness that makes you sit up?

Yes No

Do you have numbness or tingling in your arms or legs?

Yes No

When walking, do you have pain in the back of your legs (calves) that interferes with your lifestyle?

Yes No

Do you have leg pain that worsens when your legs are elevated and improves when they're lowered?

Yes No

Have you noticed new or worsening joint pain in the past year (back, hips, knees, shoulders, or hands)?

Yes No

In the past 6 months, have you accidentally leaked urine?

Yes No

Have you noticed any other symptoms that have progressively worsened over the past 12 months that concern you?

Annual Wellness Visit Questionnaire

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