The Medicare Annual Wellness Visit, or AWV, builds and then updates a personalized prevention plan: a health risk assessment, history, measurements, a cognitive check, a screening schedule, and advice. It isn’t a physical exam. Copy the free template, with every element CMS lists for the first visit, G0438, and later visits, G0439. See an initial and a subsequent example, and check the 2026 rules.
For clinicians in the United States.
Blank annual wellness visit template
FreeMEDICARE ANNUAL WELLNESS VISIT Patient: [Name, date of birth] Date of visit: [Date] Visit type: [Initial AWV, G0438, or subsequent AWV, G0439] Eligibility: [Part B start date; date of the last AWV or Welcome to Medicare visit, or none] Format: [In person, or telehealth by video] Present: [Patient, and family, caregiver, or interpreter, or none] Performed by: [Name, credentials; supervising physician if done by a team member] HEALTH RISK ASSESSMENT Completed: [Date, by the patient before the visit or with staff today, and the tool used] Self-rated health: [Excellent, very good, good, fair, or poor; frailty and physical function] Psychosocial risks: [Mood and life satisfaction, stress, anger, loneliness or isolation, pain, fatigue] Behavioral risks: [Tobacco, physical activity, nutrition, oral health, alcohol, sexual health, seat belt use, home safety] ADLs: [Dressing, feeding, toileting, grooming, walking and balance, bathing: independent, or the help needed] IADLs: [Phone, meals, housework, laundry, transport, shopping, medications, finances] HISTORY AND CARE TEAM Medical and surgical history: [Illnesses, hospital stays, operations, injuries, treatments, and changes since the last AWV] Allergies: [Drug and reaction, or none known] Medications and supplements: [Each prescription, over-the-counter drug, vitamin, calcium, and supplement, with dose] Family history: [Conditions in parents, siblings, and children, with age at diagnosis] Providers: [Primary care, specialists, behavioral health, dentist, eye care] Suppliers and services: [Pharmacy, medical equipment, home health, adult day care, home-delivered meals] MEASUREMENTS Height: [At the initial AWV] Weight and BMI: [Weight; BMI at the initial AWV, or waist circumference if more appropriate] Blood pressure: [Reading, and a repeat if high] Other: [Measurements chosen from the history, such as vision, or none] COGNITION Observation: [What you noticed during the visit: memory, word-finding, following the conversation] Reports: [Concerns from the patient, family, friends, or caregivers, or none] Brief test: [Tool and score, such as Mini-Cog, or not done and why] Result: [No concern, or a positive screen and the next step] MOOD, FUNCTION, AND SAFETY Depression risk: [Current or past depression or other mood disorder; tool and score, such as PHQ-2 or PHQ-9; required at the initial AWV] Daily function: [ADLs, and any help needed] Falls: [Falls in the past year, unsteadiness, worry about falling; gait test and result if done] Hearing: [Concerns, screen result, or hearing aids] Home and community safety: [Rugs, lighting, rails, smoke alarms, firearms, driving] OPIOIDS AND SUBSTANCE USE Opioid prescriptions: [None, or each opioid, dose, and prescriber] Opioid review: [Opioid use disorder risk factors, pain severity and plan, non-opioid options, referral if needed] Substance use screen: [Alcohol, tobacco, cannabis, other drugs; tool and score if used; referral if needed] OPTIONAL ELEMENTS Advance care planning: [Offered; declined, or done: wishes, health care agent, forms completed, minutes] Physical activity and nutrition: [Not done, or the standardized tool used and the result] PREVENTION PLAN Written screening schedule: [Each screening test and vaccine due over the next 5 to 10 years, with dates, per USPSTF and ACIP recommendations; copy given on paper, by portal, or by mail] Risk factors and conditions: [Each one, with the intervention recommended or underway] Advice and referrals: [Fall prevention, nutrition, physical activity, tobacco cessation, social engagement, weight, cognition: advice given and referrals sent] Separate care today: [None, or the problem addressed and documented as a separate service] Next AWV: [Date, at least 12 months after today] Signed: [Name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Primary care, initial AWV, G0438, in person, with her daughter
66-year-old woman, new to the practice this spring. Initial AWV, G0438. Part B began July 1, 2025, 16 months ago; no Welcome to Medicare visit and no earlier AWV, confirmed on the eligibility check. In person, 45 minutes. Her daughter joined for the second half, with her agreement. Done by the family physician, after the medical assistant went through the HRA with her.
Completed with the medical assistant before the visit, about 15 minutes. Self-rated health “fair,” down from “good” a year ago. Retired school librarian, widowed 2 years, lives alone. Lonely since her book club ended; sees her daughter on Sundays. Some days “foggy” and tired; knee pain 3 out of 10. Never smoked. Walks 20 minutes twice a week. Skips lunch most days. Always wears a seat belt. Independent in all ADLs. IADLs: shops, cooks, and drives; her daughter took over paying the bills in August, after two late notices.
Hypertension for 10 years, high cholesterol, and urge incontinence. Hysterectomy at 48 for fibroids. One fall in March, below. No hospital stays. No known drug allergies. Medications, from her bottles: lisinopril 10 mg daily, atorvastatin 20 mg daily, oxybutynin 5 mg twice daily since February, calcium with vitamin D, and melatonin 3 mg at night. Family history: mother had Alzheimer’s disease from about 75; father died of a heart attack at 70; brother has type 2 diabetes. Providers: this practice, a gynecologist last seen 3 years ago, a dentist, and an optometrist. Suppliers: one pharmacy; no equipment or home services.
Height 160 cm (63 in), weight 72 kg (159 lb), BMI 28.1. BP 142/86, repeat 136/84 after 5 minutes’ rest. Vision with glasses 20/30 in each eye.
Asked the same question about her medications twice during the visit. Her daughter has noticed repeated questions on the phone, the two missed bills, and one afternoon in September when she got lost driving home from a store she has used for years. She says her memory is “not what it was.” Mini-Cog 2 of 5: recalled 2 of 3 words; all 12 numbers on the clock, but the hands didn’t show the time asked. Positive screen. No signs of delirium: alert, attention held through the visit, no recent illness.
No past depression. PHQ-2 2, a negative screen; loneliness noted from the HRA. Independent in ADLs. Falls: tripped on her front steps in March and bruised her wrist, no care sought; unsteady getting up at night to pass urine; worried about falling. Yes to all three key fall questions. Timed Up and Go 13.8 seconds, over the 12-second flag; slow to stand, steadied herself on the chair. Hearing: hard to follow conversation in groups; missed whispered words on the left. Home: split-level house, loose rugs in the hall, no grab bars or night lights; smoke alarms tested; no firearms. Drives in the daytime.
No opioid prescriptions. AUDIT-C 2: a glass of wine 2 to 4 times a month, never more than 2. No tobacco, cannabis, or other drugs. No referral needed.
Advance care planning offered. She wants to name her daughter as her health care agent, and asked to do it with her at the cognitive visit, while she can take a full part. Physical activity and nutrition risk assessment not done.
Written schedule, given to her: mammogram due September 2027, last one September 2025; colonoscopy at 58 normal, next at 68; no cervical screening after a hysterectomy for a benign cause; bone density test ordered today, never done; A1c 5.6% in 2024, repeat in 2027; hepatitis C tested once, negative. Vaccines: influenza and a pneumococcal conjugate vaccine given today; recombinant zoster, 2 doses, at her pharmacy. Risk factors and interventions: 1, positive cognitive screen with a family history of Alzheimer’s disease: separate cognitive assessment and care planning visit in 2 weeks with her daughter, with B12, TSH, CBC, and a metabolic panel beforehand, and a review of oxybutynin, which is anticholinergic. 2, fall risk: full fall risk assessment next week, physical therapy referral for strength and balance, and rugs out, night lights, and a grab bar. 3, hearing: audiology referral. 4, loneliness: the senior center’s book group and library volunteering. 5, BP 136/84 on lisinopril: home readings for 2 weeks. 6, skipped meals: a simple lunch plan. Separate care today: none. Next AWV: November 2027.
Primary care, subsequent AWV, G0439, nurse-led, with the physician for advance care planning
78-year-old man. Subsequent AWV, G0439; last AWV here 13 months ago. In person, with his wife. The practice nurse did the visit under the physician’s direct supervision; the physician joined for advance care planning.
Updated on the patient portal 3 days before the visit. Self-rated health “good.” Mood good; no loneliness. Knee pain 5 out of 10 on stairs. Walks 30 minutes on 4 days a week, less since his knee got worse. Follows a diabetes plate at home; one beer a month. Always wears a seat belt. Independent in all ADLs. IADLs: his wife manages their finances, as she always has; he fills his own weekly pill box.
Since the last AWV: right knee osteoarthritis has worsened, and his orthopedic surgeon has booked a knee replacement for January. No hospital stays. Known conditions: type 2 diabetes for 15 years, A1c 7.4% at his diabetes visit last month; hypertension; hearing loss. Allergy: sulfa, rash. Medications: metformin 1,000 mg twice daily, empagliflozin 10 mg daily, losartan 50 mg daily, atorvastatin 40 mg daily, tramadol 50 mg at bedtime since August, acetaminophen as needed, and vitamin D 1,000 units daily. Family history: no change. Providers: this practice, his orthopedic surgeon, an ophthalmologist for yearly diabetic eye exams, an audiologist, and a dentist. Suppliers: one pharmacy; meter and test strips by mail.
Weight 84 kg (185 lb), down 2 kg from last year; he cut out evening snacks. BP 128/76.
Followed the visit easily and gave his own history with dates. His wife has no concerns. Mini-Cog 5 of 5. No concern.
PHQ-2 0 on the HRA. Independent in ADLs. No falls; steady on his feet, uses the stair rail. Hearing aids worn and working well. Single-story house; grab bars added last year. Drives in the daytime only, by choice. No firearms.
Tramadol 50 mg at bedtime, prescribed by his orthopedic surgeon until surgery. Opioid review: no personal or family history of substance use disorder, no mental health condition, no benzodiazepines or other sedatives. Pain 5 out of 10 on stairs, 2 at rest; sleeps through the night. Non-opioid options: acetaminophen 1,000 mg three times a day on a schedule rather than as needed, and diclofenac gel on the knee. Told that tramadol can add to dizziness and fall risk. No referral needed; the surgeon stays the prescriber. AUDIT-C 1. Former smoker, 25 pack-years, quit 36 years ago. No cannabis or other drugs.
Advance care planning with the physician, 25 minutes, face to face with him and his wife; he wanted it done before his surgery. What matters most: living at home and knowing his family. He named his wife as his health care agent and his son as the alternate, and completed and signed his state’s advance directive form, with witnesses as the form requires. Wishes: full treatment, including the surgery and any complications, while a return to life at home is likely; comfort-focused care, with no CPR and no breathing machine, if a severe illness leaves no real chance of knowing his family again. A POLST form isn’t indicated now; revisit if his health changes. Copies to him, his chart, and his surgeon, with his consent. Billed as 99497 with modifier 33 on the AWV claim. Physical activity and nutrition risk assessment not done.
Written schedule, updated and given to him: colonoscopy at 70 normal; at his age, more colorectal screening is an individual decision, and he chose to stop. PSA screening not recommended at 70 and older. Abdominal aortic aneurysm ultrasound at 70, normal; no repeat. Lung cancer screening not indicated: quit more than 15 years ago. Diabetic eye exam due in February; urine albumin test with his January labs. Vaccines: influenza given today; RSV in 2024, pneumococcal in 2023, and recombinant zoster in 2022, all complete; Tdap in 2019, next tetanus booster in 2029. Risk factors and interventions: 1, type 2 diabetes: managed at his diabetes visits, next in January, with a foot exam and labs. 2, knee osteoarthritis on tramadol: scheduled acetaminophen and diclofenac gel; pre-surgery exercises from the orthopedic program. 3, hypertension: at target. 4, hearing loss: aided, yearly audiology. 5, advance directive completed today. Advice: keep walking on flat ground, within knee comfort. Separate care today: none. Next AWV: November 2027 or later.
The AWV is defined in federal regulation and CMS guidance. These sources set who qualifies, how often, and what the note has to show.
The patient’s own answers, collected before or during the visit, on a tool that takes no more than 20 minutes. The rest of the visit builds on it.
Avoid: Filing the HRA without reading it. Carry each positive answer into the risk factor list or the plan.
The medical, surgical, and family history, every medication and supplement, and everyone who regularly provides care.
Avoid: A provider list with only physicians. CMS asks for suppliers too, and behavioral health and community services count.
Height, weight, BMI or waist circumference, and blood pressure at the first AWV; weight and blood pressure at later ones. Add others the history calls for.
Avoid: Turning the measurements into a physical exam. The AWV has none; if you examine a problem, document it as a separate service.
A check for cognitive impairment at every AWV: what you observed, what the patient and family report, and a brief test when you use one.
Avoid: Diagnosing dementia from a screen. A positive Mini-Cog leads to a fuller assessment, not a label.
At the first AWV, a depression risk review with a standardized tool, and a review of daily function, falls, hearing, and home safety. At later visits, the updated HRA covers these.
Avoid: A positive fall screen with no next step. Book a fall risk assessment, or start one today.
Two required elements: a review of any current opioid prescription, and a screen for substance use disorders.
Avoid: Leaving the opioid line blank when there is no prescription. Write “none,” so a reviewer can see it was checked.
Advance care planning, when the patient wants it, and, from 2026, a physical activity and nutrition risk assessment.
Avoid: “ACP discussed” and nothing else. Record the wishes, the agent, the forms, and the time.
The written screening schedule, the list of risk factors and conditions with what is being done for each, and personalized advice and referrals.
Avoid: A plan that stays in the chart. The patient should leave with the written schedule.
The AWV has no hands-on exam, and a head-to-toe exam doesn’t make one. Tell patients what the visit covers when they book, since Medicare doesn’t pay for a routine physical.
“Cognition intact” on its own doesn’t show a check was done. Record what you observed, what family reported, and the tool and score if you used one.
Both are required at every AWV. When there is no opioid prescription, write “none”; when a screen is positive, record the referral.
Changing diabetes medicines or working up a new symptom is a separate service, with its own documentation, modifier 25, and cost sharing. Tell the patient before you start.
Vero Scribe writes the wellness visit note in your template from the visit, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your EHR or export it to Word or PDF. Vero works in 60+ languages.
At the first AWV: a health risk assessment, medical and family history, a list of current providers and suppliers, height, weight, BMI, and blood pressure, a cognitive check, a depression risk review, a review of function and safety, an opioid review, a substance use screen, a written screening schedule, a list of risk factors with interventions, and personalized advice. Advance care planning is optional. The template has a field for each.
No. The AWV is a conversation to build a prevention plan, with routine measurements but no hands-on exam. The patient pays nothing for it if you accept assignment, but Medicare doesn’t cover a routine physical. If you examine or treat a problem at the same visit, document it as a separate service, billed with modifier 25, which has the usual deductible and coinsurance.
After their first 12 months of Part B, and not within 12 months of a Welcome to Medicare visit. They don’t need to have had a Welcome to Medicare visit first. After that, one AWV every 12 months. G0438 is paid once in a lifetime, even if the first AWV was at another practice, so ask or check eligibility before the visit. Every later AWV is G0439.
Not in 2026. CMS kept code G0136 but changed it to a standardized physical activity and nutrition risk assessment, which is now the optional add-on. The HRA still asks about stress, loneliness, and social isolation, and you can still record social needs and refer.
Yes. A physician, physician assistant, nurse practitioner, or clinical nurse specialist can do it, and so can a licensed medical professional or a team, such as a nurse, health educator, or dietitian, under a physician’s direct supervision. Name who did each part, and the supervising physician.
Yes. Copy it, or download it as a Word or text file. No account needed.
The preventive visit: interval history, screening and vaccines due, full exam, and counseling.
The one-time IPPE, G0402: history, depression and safety review, exam with visual acuity, end-of-life planning, and the written plan.
The standing summary at the front of the chart: problems, history, medications, allergies, immunizations, risks, and reminders, kept current.
Screening, vaccines, and counselling due at an adult periodic health review, by age and sex, with a next due date on every line.
The first visits after arrival: interpreter, journey, IFHP coverage, catch-up vaccines, screening by region, mental health, and social needs.
Notes for visits with older adults, drafted for your review.
How to score the 3-word recall and the clock, with the cutoffs.
Prevention visits and screening plans, drafted from the conversation.
How to run it, and the 12-second fall risk flag.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
No credit card required. 10 free actions every month.