Healthcare Wellness Form PDF Details

If you are like most people, you probably don't think about your health until you get sick. And even then, it's only because you have to go to the doctor or take a medication. But what if there were another way? What if you could make simple changes to your lifestyle that would help prevent illness in the first place? The good news is, there is. Healthcare wellness forms can help you do just that. By making small changes to your diet and exercise habits, you can improve your overall health and well-being. So why not give it a try? It might be just what you need to stay healthy and happy for years to come.

The table contains information regarding the healthcare wellness form. You can read it prior to writing the form.

Form NameHealthcare Wellness Form
Form Length2 pages
Fillable fields72
Avg. time to fill out14 min 58 sec
Other namesshbp provider notification form online, unitedhealth personal shbp, uhc annual wellness form, uhc biometric screening

Form Preview Example

2022 Annual Care Checklist

Nothing is more important than your health. That's why you can count

on UnitedHealthcare® to help you get the care you need, when you need it. Take this checklist to your next appointment.

Good preventive care helps catch health issues early when they may be easier to treat. Have this checklist handy at your next appointment. Together, you and your primary care provider (PCP) can decide which tests and health care services are right for you. Recommended preventive care services may include the following1:

Once a year


Date done

Flu shot (every flu season)








Vaccine review (see what shots you



may be due for)



Annual wellness visit/


Date done


routine physical




Blood pressure check








Head-to-toe examination






Height, weight and body mass



index (BMI)






Lifestyle screening check such as



alcohol use, help quitting tobacco



and healthy eating, if applicable.



As recommended by your PCP


Date done


Cervical cancer screening (Pap





smear) for women ages 21–65






Cholesterol screening






Dental exam






Bone mineral density test to screen



for osteoporosis






Eye exam






Fasting blood sugar screening






Hearing exam






As needed

Date done



Colon cancer screening


(for adults age 50 or older)




Hepatitis C virus infection


screening (for people at high risk


and a one-time test for adults born


between 1945–1965)




Mammogram screening


(every year starting at age 45;


starting at age 55, it can change to


every other year2)




For people with diabetes

Date done



Exam to detect diabetes-related


eye issues




Exam to detect diabetes-related


foot issues




Hemoglobin A1c (HbA1c)




LDL cholesterol




Statin medication, if clinically






Tests to monitor for kidney disease




See back for important topics to prepare for your next appointment.

Important topics to discuss with your PCP

Prepare for your appointment by filling in the information below. Then, write down recommendations your PCP has about these topics and treatment options during your visit.


Write down your prescriptions, over-the-counter medications, supplements and vitamins youʼre taking, or having difficulty taking. Ask:

Am I taking them correctly?

Are there any side effects?

Is there a lower-cost option?

Tests and treatments

Discuss tests ordered during your appointment. Ask:

When can I expect results?

Will I receive a follow-up call?

Do I need a follow-up appointment?

Care team

List any specialists or other providers you see. This will help your PCP coordinate your overall care.

Health evaluations

Mental health

Discuss your mental health with your PCP. Let them know if youʼre feeling sad or blue, or are having difficulty sleeping.

Or, discuss challenges youʼre experiencing in planning, or memory loss that disrupts daily life.

Physical health

Discuss your physical health with your PCP, including if youʼre experiencing pain that interferes with your regular activities, work or social life.

Risk of falls

I have had a fall

I have problems with balancing or walking

I don't have problems with balancing or falling

Other health concerns

Bladder control

I have problems with bladder control

I have problems with leaking of urine

I don't have bladder control or urine leakage problems

Physical activity

Start exercising

Increase exercise

Maintain current exercise level

If you have questions, please call the Customer Service number on your member ID card.

From scheduling your next checkup appointment to finding a provider, you can count on us to help you get the care you need, when you need it.

1This is a list of suggested screenings. Coverage for these screenings (including how often they are covered) may vary by plan. If you have questions about your specific benefits or coverage details, please call Customer Service at the number on your member ID card or check your Evidence of Coverage.

2American Cancer Society, 2021.

© 2022 United HealthCare Services, Inc. All Rights Reserved.




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Make sure you type in the next details to fill out the united healthcare wellness form for doctor PDF:

unitedhealth personal shbp empty fields to fill out

Type in the information in the As, recommended, by, your, PCP Dated, one Cholesterol, screening Dental, exam Eye, exam Fasting, blood, sugar, screening Hearing, exam Hemoglobin, AcH, bAc LDL, cholesterol and Tests, to, monitor, for, kidney, disease area.

Finishing unitedhealth personal shbp part 2

Determine the key data in the Medications, Tests, and, treatments Care, team Mental, health and Physical, health box.

Filling out unitedhealth personal shbp stage 3

Take the time to identify the rights and responsibilities of the parties within the Health, evaluations, Risk, of, falls Other, health, concerns Bladder, control and Physical, activity section.

Completing unitedhealth personal shbp part 4

Step 3: Click "Done". You can now upload the PDF form.

Step 4: Make sure you stay away from potential issues by preparing no less than a pair of copies of your form.

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