MEDICARE 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]