Medicare Annual Wellness Visit Form PDF Details

The Medicare Annual Wellness Visit Form is a required document for seniors who receive Medicare benefits. The form must be completed by a health care provider and filed with Medicare prior to the senior's annual wellness visit. The purpose of the form is to help ensure that seniors receive appropriate preventive care services.

Here is the data concerning the file you were looking for to complete. It will tell you the time it may need to complete medicare annual wellness visit form, exactly what parts you will have to fill in, and so forth.

Form NameMedicare Annual Wellness Visit Form
Form Length2 pages
Fillable fields130
Avg. time to fill out26 min 30 sec
Other namesmedicare annual wellness visit forms, medicare annual wellness visit template 2020 pdf, medicare wellness exam form pdf, awv form

Form Preview Example


Please complete this checklist before seeing your doctor or nurse. Your responses will help you receive the best health care possible.

1.What is your age?

65-69. 70-79. 80 or older.

2.Are you a female or a male?

Male. Female.

3.During the past four weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad, or downhearted and blue?

Not at all.



Quite a bit.


4.During the past four weeks, has your physical and emotional health limited your social activities with family friends, neighbors, or groups?

Not at all.



Quite a bit.


5.During the past four weeks, how much bodily pain have you generally had?

No pain.

Very mild pain.

Mild pain.

Moderate pain.

Severe pain.

6.During the past four weeks, was someone available to help you if you needed and wanted help?

(For example, if you felt very nervous, lonely or blue; got sick and had to stay in bed; needed someone to talk to; needed help with daily chores; or needed help just taking care of yourself.)

Yes, as much as I wanted.

Yes, quite a bit.

Yes, some.

Yes, a little.

No, not at all.

Your Name___________________________________


Today’s date__________________________________

Your date of birth_______________________________

7.During the past four weeks, what was the hardest physical activity you could do for at least two minutes?

Very heavy.




Very light.

8.Can you get to places out of walking distance without help? (For example, can you travel alone on buses, taxis, or drive your own car?)

Yes. No.

9.Can you go shopping for groceries or clothes without someone’s help?

Yes. No.

10.Can you prepare your own meals?

Yes. No.

11.Can you do your housework without help?

Yes. No.

12.Because of any health problems, do you need

the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house?

Yes. No.

13.Can you handle your own money without help?

Yes. No.

14.During the past four weeks, how would you rate your health in general?


Very good.





PN 900 PAGE 1

Patient Name_______________________________________ DOB____________________Today’s Date_________________

15.How have things been going for you during the past four weeks?

Very well; could hardly be better.

Pretty well.

Good and bad parts about equal.

Pretty bad.

Very bad; could hardly be worse.

16.Are you having difficulties driving your car?

Yes, often.



Not applicable, I do not use a car.

17.Do you always fasten your seat belt when you are in a car?

Yes, usually.

Yes, sometimes.


18.How often during the past four weeks have you been BOTHERED by any of the following problems?













Falling or dizzy when standing up

Sexual problems

Trouble eating well

Teeth or denture problems

Problems using the telephone

Tiredness or fatigue

19.Have you fallen two or more times in the past year?

Yes. No.

20.Are you afraid of falling?

Yes. No.

21.Are you a smoker?


Yes, and I might quit.

Yes, but I’m not ready to quit.

Checklist to bring to your appointment:

-Medical records, including immunization records -Family health history in as much detail as possible

-Full list of medications, supplements-how often & how much taken -Full list of current providers & suppliers involved in your care

22.During the past four weeks, how many drinks of wine, beer, or other alcoholic beverages did you have?

10 or more drinks per week.

6-9 drinks per week.

2-5 drinks per week.

One drink or less per week.

No alcohol at all.

23.Do you exercise for about 20 minutes three or more days a week?

Yes, most of the time. Yes, some of the time.

No, I usually do not exercise this much.

24.Have you been given any information to help you with the following:

Hazards in your house that might hurt you?

Yes. No.

Keeping track of your medications?

Yes. No.

25.How often do you have trouble taking medicines the way you have been told to take them?

I do not have to take medicine.

I always take them as prescribed.

Sometimes I take them as prescribed.

I seldom take them as prescribed.

26.How confident are you that you can control and manage most of your health problems?

Very confident.

Somewhat confident.

Not very confident.

I do not have any health problems.

27.What is your race? (Check all that apply.)


Black or African American.


Native Hawaiian or Other Pacific Islander.

American Indian or Alaskan Native.

Hispanic or Latino origin or descent.


Thank you very much for completing your Medicare Health History. Please give the completed form to your doctor or nurse.

PN 900 PAGE 2

How to Edit Medicare Annual Wellness Visit Form Online for Free

The process of completing the medicare wellness visit form pdf is actually effortless. Our experts made sure our PDF editor is easy to utilize and can help complete virtually any PDF without delay. Learn about several simple steps you will have to take:

Step 1: On the following webpage, press the orange "Get form now" button.

Step 2: Once you get into the medicare wellness visit form pdf editing page, you will see all the actions it is possible to take with regards to your document within the top menu.

The next areas are going to make up your PDF file:

stage 1 to completing medicare wellness exam template

You should prepare the Yes, No Can, you, prepare, your, own, meals Yes, No Can, you, do, your, housework, without, help Yes, No Yes, No Can, you, handle, your, own, money, without, help Yes, No and Excellent, Very, good, Good, Fair, Poor box with the essential information.

medicare wellness exam template YesNo, Canyouprepareyourownmeals, YesNo, Canyoudoyourhouseworkwithouthelp, YesNo, YesNo, Canyouhandleyourownmoneywithouthelp, YesNo, and ExcellentVerygoodGoodFairPoor fields to insert

Jot down the essential data in Excellent, Very, good, Good, Fair, Poor continued, and PN, page area.

Entering details in medicare wellness exam template part 3

Inside the field DOB, Todays, Date Yes, usually, Yes, sometimes, No and Yes, No list the rights and responsibilities of the parties.

part 4 to entering details in medicare wellness exam template

End by looking at the next areas and filling in the suitable information: Yes, usually, Yes, sometimes, No modeS, r, eveN item, oS net, f s, yaw, A Yes, No Are, you, afraid, of, falling Yes, No Are, you, a, smoker Yes, No Keeping, track, of, your, medications Yes, No and What, is, your, race, Check, all, that, apply

step 5 to entering details in medicare wellness exam template

Step 3: Press the Done button to be certain that your finished form may be exported to any device you end up picking or forwarded to an email you specify.

Step 4: To avoid any sort of hassles down the road, you will need to get minimally a few duplicates of your document.

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