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Annual Physical Exam Visit Context - Annual physical / preventive visit; patient goals and concerns for today. - Acute issues to address today vs defer. History Update - Interval medical, surgical, hospitalizations, and specialist care. - Medications, allergies, family history updates, and social history (tobacco, alcohol, substances, sexual health, safety, occupation). - Reproductive health / contraception as relevant. Review of Systems - Age-appropriate ROS; document pertinent positives/negatives. Exam - Vital signs, BMI, and exam systems performed (general, HEENT, neck, CV, lungs, abdomen, skin, neuro, musculoskeletal, genital/breast/prostate as indicated and consented). Screening & Immunizations - Cancer, metabolic, infectious, bone health, and behavioral screenings: status, due, completed, or deferred with reason. - Immunization review and vaccines given today. Assessment - Preventive visit complete; chronic conditions status if reviewed. - Abnormal findings requiring workup. Plan - Labs/imaging ordered; referrals; lifestyle counseling (diet, activity, sleep, substances). - Medication adjustments if made today. - Personalized prevention timeline and return interval. - After-visit instructions summarized.
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Visit Context 45-year-old annual physical. Goals: review cholesterol and colon cancer screening options. Also mild seasonal allergies. History / ROS PMH: HTN on lisinopril. No hospitalizations. Former smoker (quit age 30). Exercises 2×/week. Alcohol socially. ROS otherwise negative except intermittent sneezing/itchy eyes. Exam BP 126/78, BMI 27.4. HEENT: mild nasal mucosal edema. Heart regular; lungs clear; abdomen soft; skin without concerning lesions; brief neuro nonfocal. Screenings / Vaccines Lipid panel due—ordered. Colonoscopy discussed (family history father polyps age 60)—shared decision for colonoscopy vs FIT; patient chooses FIT this year. Tdap up to date; flu deferred to fall. Assessment / Plan 1) Annual physical—healthy adult with controlled HTN. 2) Allergic rhinitis—cetirizine PRN, saline rinses. FIT kit provided; fasting lipids; continue lisinopril. Lifestyle: increase aerobic activity toward 150 min/week. Return 1 year or PRN; AVS reviewed.
What the product actually does with your template.
Paste this content into My Templates, or start from a specialty-generated template and edit the sections.
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Start free, paste the template, and see how Wavo documents in your structure.