Healthcare Wellness Form PDF Details

In an era where health management has become more vital than ever, the Healthcare Wellness form emerges as a key tool for individuals aiming to maintain or enhance their wellness. At the heart of this initiative is the 2022 Annual Care Checklist, designed to streamline the process of getting crucial preventative care. This checklist, a comprehensive guide endorsed by UnitedHealthcare®, ensures that individuals can meticulously plan their healthcare journey, making the most out of every medical appointment. It encourages discussions between patients and their primary care providers (PCP) to tailor a personalized health care strategy, focusing on various medical exams and lifestyle assessments. From routine vaccinations like flu shots to specific screenings such as cholesterol levels, cervical cancer, and diabetes-related conditions, the form encompasses a broad spectrum of health markers. Not only does it facilitate critical evaluations for mental and physical health, but it also addresses the importance of discussing care coordination with specialists and managing medications effectively. With an emphasis on preventive care's power to detect health issues at an early stage, the checklist acts as a roadmap for individuals to navigate their health care with confidence. By providing a structured outline for essential health discussions, the form underscores the significance of proactive health management, ensuring that users can access and maximize the benefits of their healthcare plan.

Form NameHealthcare Wellness Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesuhc annual wellness form, city of charlotte biometric screening form, shbp notification online, 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 uhc biometric screening PDF:

uhc annual wellness form empty fields to fill out

Type in the information in the As recommended by your PCP, Date done, Cervical cancer screening Pap, Cholesterol screening, Dental exam, Bone mineral density test to, Eye exam, Fasting blood sugar screening, Hearing exam, Exam to detect diabetesrelated, Hemoglobin Ac HbAc, LDL cholesterol, Statin medication if clinically, Tests to monitor for kidney disease, and See back for important topics to area.

Finishing uhc annual wellness form part 2

Determine the key data in the Medications, Tests and treatments, Write down your prescriptions, Discuss tests ordered during your, Care team, List any specialists or other, Mental health, Discuss your mental health with, Or discuss challenges youre, and Physical health box.

Filling out uhc annual wellness form stage 3

Take the time to identify the rights and responsibilities of the parties within the Physical health, Discuss your physical health with, Health evaluations Risk of falls, I have had a fall, I have problems with balancing or, I dont have problems with, Other health concerns, Bladder control, I have problems with bladder, I have problems with leaking of, I dont have bladder control or, Physical activity, Start exercising, Increase exercise, and Maintain current exercise level section.

Completing uhc annual wellness form 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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