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Annual wellness visit (AWV) template
Built for annual wellness visits where health risk assessment, screenings, immunization review, and a personalized prevention plan need a clear, auditable structure—not a problem-focused sick visit.
Template content
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Annual Wellness Visit (AWV) Visit Type - Initial Preventive Physical Examination (IPPE), Initial AWV, or Subsequent AWV as applicable. - Patient goals for today’s wellness visit. Health Risk Assessment (HRA) - Self-reported health status, ADLs/IADLs, fall risk, home safety, depression/anxiety screening context, and social determinants as discussed. - Document screening tools used (e.g., PHQ-2/9, fall risk questions) and results if provided—do not invent scores. Medical / Surgical / Family / Social History Update - Interval changes to diagnoses, surgeries, medications, allergies, tobacco/alcohol/substance use, and family history. - Advance care planning / advance directives status if discussed. Review of Systems (Preventive Focus) - Pertinent positives/negatives relevant to aging, chronic disease surveillance, and preventive counseling. Medications & Allergies - Current medication list with adherence notes; allergies and reactions. Exam - Vital signs, BMI/weight trend, and focused exam as performed for wellness context. Cognitive / Functional / Mood Assessment - Cognitive screen or clinical observation; functional status; mood/depression screening as performed. Screening & Immunization Status - Age-appropriate cancer, metabolic, bone health, and infectious disease screenings (status, due/overdue, deferred with reason). - Immunization review and recommendations (influenza, pneumococcal, shingles, COVID-19, Td/Tdap, others as indicated). Risk Factors & Chronic Conditions - Active chronic conditions relevant to prevention planning (e.g., HTN, DM, hyperlipidemia, obesity, CAD). - Modifiable risks: tobacco, alcohol, physical inactivity, nutrition, fall risk. Assessment - Wellness/preventive visit assessment; chronic conditions stable/unstable as relevant. - Any acute issues addressed today (briefly) or deferred. Personalized Prevention Plan - Recommended screenings, immunizations, lifestyle counseling, referrals (e.g., nutrition, PT, behavioral health), and follow-up interval. - Patient education and shared decision-making documented.
When to use this template
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
- Separates wellness elements (HRA, screenings, prevention plan) from acute problem lists.
- Prompts cognitive, functional, and fall-risk review common to AWV workflows.
- Keeps immunization and screening status visible for longitudinal preventive care.
- Easy to customize for Medicare AWV vs commercial annual physical language.
- 1Medicare Annual Wellness Visits
- 2Medicare Advantage wellness encounters
- 3Primary care preventive wellness appointments
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Visit Type Subsequent Medicare Annual Wellness Visit. Patient goals: review screening schedule and discuss fall prevention. HRA / Screening PHQ-2 negative. Reports independent ADLs/IADLs. One near-fall at home last month when rising at night; no injury. Lives alone with daughter nearby. Exam / Cognitive Vitals stable; BMI 29.1. Alert, oriented ×3; no acute cognitive concerns on clinical assessment. Gait steady with cane for community distances. Screenings & Immunizations Colonoscopy completed 2023 (normal). Mammogram overdue—scheduled. Flu vaccine given today. Pneumococcal series complete. Shingles vaccine previously received. Assessment Subsequent AWV completed. Hypertension and type 2 diabetes, both stable on current regimen. Increased fall risk; osteoporosis screening discussed. Personalized Prevention Plan Mammogram referral placed. Home safety counseling and night-light recommendation provided. Continue current HTN/DM meds; labs at next chronic care visit in 3 months. Return for AWV in 12 months or sooner PRN.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Related templates
Put this template to work on your next visit
Start free, paste the template, and see how Wavo documents in your structure.