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 Annual Wellness Visits 

Regular visits with your primary care physician are very important in maintaining a healthy lifestyle.  An Annual Wellness Visit is a type of preventative healthcare that focuses on maintaining wellness and taking proactive measures for possible future health concerns.  Wellness visits or wellness exams are typically annual and are separate from other medical visits related to illness or injuries. 

During your wellness exam, you will be asked to complete a Health Risk Assessment, which is a series of questions about your health history, family health history, and any changes in your health within the past year.  It is very important that you take the time to review each question thoroughly.  Below, you will find a list of the questions that your healthcare provider or nurse will ask you prior to your appointment if you are been seen through Televisit. 

Health Risk Assessment Form

Behavioral Risk Factors:


Do you usually exercise at least 20 minutes a day?                                                                                                          


Do you usually eat a diet that has at least 5-6 servings of fruit and vegetables?

Do you eat 2-3 servings of whole-grain and fiber daily?  (oatmeal, whole wheat bread)              

Do you eat less than 2 servings of high-fat or fried foods daily?  


Do you always fasten your seat belt when you are in the car?


Do you protect yourself from the sun when you are outdoors?

Biometric Measures (self-reported)


Is your doctor treating you for high blood pressure?


Is your doctor treating you for high cholesterol?  


Have you ever been told by a doctor or a health professional that you have diabetes or high blood sugar?

Psychosocial Risk Factors:


How would you generally create your health? (circle: 1=poor  10=excellent)     1   2   3   4   5   6   7   8   9   10


In the past 4 weeks, was someone available to help you if you needed or wanted help?


Are you sleeping 6-8 hours at night?


Do you or any of your friends or family members have any concerns with your memory? 

Activities of Daily Living:


Eating        Getting dressed        Bathing        Walking        Using the toilet        None

Are you able to independently manage financial matters?

Are you able to travel independently in your own car or on public transportation?

Can you do everything you were able to do last year?

If not, what do you need help with? 

Disease Prevention:


Are you taking an Aspirin daily?


Have you or anyone had concerns about your hearing?

Many people experience leakage of urine, also called urinary incontinence.  In the past 6 months, have you

experienced leaking of urine?                                                                                                                                                           

Fall Risk Screening:


No falls ___   I fall without injury ___   2 falls without injury ___   2 falls with injury ___

Staying active and making your home safer can prevent falls.  You can improve the safety of your home by removing loose scatter rugs, correct uneven surfaces, improve lighting and adding handrails. 

Alcohol Use:

Did you have a drink containing alcohol in the past year?

If yes, how often did you have a drink containing alcohol in the past year?


Monthly or less ___   2-4 times a month ___   2-3 times a week ___   4 or more times a week ___

If yes, how many drinks did you have on a typical day when you were drinking in the past year?


1-2 ___   3-4 ___   5-6 ___   7-9 ___   10 or more

If yes, how often did you have 6 or more drinks on one occasion in the past year?


Never ___   Less than monthly ___   Monthly ___   Weekly ___   Daily or almost daily ___

Pain Management:

Do you currently use pain medication prescribed by a doctor?  

List any pain medication prescribed by your doctor:

If yes,  check the applicable statements:

(Some medicines are prescribed to treat pain.  With prolonged use, pain-relieving effects may lessen and pain can become worse.  In addition, the body can develop dependence.  The following questions will help your provider determine if changes need to be made to your medication regimen). 

___ At times, I have taken more of the prescribed pain medication that I intended to.

___ I have wanted to stop or cut down using or control my use of prescribed pain medication. 

___ I have spent a lot of time getting or using my prescribed pain medication. 

___ I have a strong desire or urge to use my prescribed pain medication. 

___ The use of my prescribed pain medication has caused problems with other people. 

___ I have had to give up or spend less time working or enjoying hobbies because of prescription pain medication.

___ I still use my prescribed pain medication even though I know it has caused problems like depression, anxiety or irritability. 

___ I have found that I need much more of prescribed pain medication to get the same effect 

___ When I reduced or stopped using my prescribed pain medication, I felt sick (aches, shaking, fever, diarrhea, nausea, sweating, etc. 

___ None of these statements apply to me. 

Procedures that you have had performed outside of Boice-Willis Clinic:

Please note any of the following procedures performed OUTSIDE of Boice-Willis Clinic or have declined to have performed.  This information will be updated in your Boice-Willis Clinic electronic medical record. 

Colonoscopy: - Outside of BWC (please list location): ______________________________________________      

Mammogram - Outside of BWC (please list location): ______________________________________________   

Pap Smear (female)  - Outside of BWC (please list location): _________________________________________

Prostate Exam (male) - Outside of BWC (please list location): _________________________________________

Pneumonia Vaccine - Outside of BWC (please list location): _________________________________________

Tetanus - Outside of BWC (please list location): _________________________________________

Flu Shot - Outside of BWC (please list location): _________________________________________

Please list other health care providers you may see and health supply companies you may use:

Thank you for completing this Health Risk assessment.  Your provider will review this with you.  As a reminder and Annual Wellness Visit is covered by Medicare.  This visit is a "hands-off " visit that focuses on disease prevention and preventative care.  If chronic medical problems or new problems are addressed by your provider there may be additional charges for these services. 

Preparing for Your TeleVisit
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