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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.

Question	Answer
Form Name	Healthcare Wellness Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	72
Avg. time to fill out	14 min 58 sec
Other names	shbp provider notification form online, unitedhealth personal shbp, uhc annual wellness form, uhc biometric screening

12

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)
Flu shot (every flu season)

Vaccine review (see what shots you
may be due for)
Annual wellness visit/		Date done
Annual wellness visit/
routine physical
routine physical
Blood pressure check
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
As recommended by your PCP		Date done
Cervical cancer screening (Pap
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
appropriate

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.

Medications

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.
Y0066_SPRJ67225_C	SPRJ67225

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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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