Get Wellness Visit Form

The Wellness Visit Form is an essential tool that helps healthcare providers understand your health needs and concerns. This guide will walk you through each section of the form to ensure that you can complete it accurately and effectively in an online format.

Follow the steps to successfully complete the form

1. Press the ‘Get Form’ button to access the Wellness Visit Form and open it in your preferred editor.
2. Start by entering your name and birthdate at the top of the form. Ensure the details are accurate as they are crucial for identification.
3. List the members of your current care team, including your healthcare providers and suppliers, in the designated space provided.
4. Self-assess your health over the past four weeks by selecting your overall health rating from the options provided: Excellent, Good, Fair, or Poor.
5. Indicate whether you require assistance with personal care tasks due to any health issues by checking either 'Yes' or 'No'.
6. In the psychosocial health section, respond to the prompts regarding your emotional health over the past two weeks by rating each statement using a scale from 0 to 3.
7. Proceed to the health and habits section. Here, answer questions about alcohol consumption, dietary habits, exercise frequency, and general health practices.
8. Evaluate your ability to carry out activities of daily living by rating the difficulty of various tasks as None, Mild, Moderate, Severe, or Complete.
9. Answer questions related to cognitive impairment, risk factors for cardiac conditions, and any preventive services you have received by selecting 'Yes' or 'No' as appropriate.
10. Finally, on the last section of the form, note any additional topics you would like to discuss with your provider and check the corresponding boxes.
11. Once you have filled out all sections, ensure that you review your responses for accuracy. You can then save changes, download, print, or share the completed form as needed.

Complete your Wellness Visit Form online today for a comprehensive assessment of your health needs.