Homepage Fill Out Your Healthcare Wellness Form
Article Structure

Your health is your most valuable asset, and taking proactive steps to maintain it is essential. The Healthcare Wellness form serves as a practical guide for patients visiting their healthcare provider, offering a comprehensive checklist to ensure that all necessary preventive care measures are taken. This form outlines a variety of recommended screenings and services, categorized by frequency, including annual vaccinations, routine physical exams, and tests for specific health conditions based on individual needs. During your visit, you’ll find space to record vital information, discuss medications and treatments, and address both physical and mental health concerns with your primary care provider (PCP). Moreover, the checklist encourages open dialogue about any additional health worries, providing a structure to keep your health care organized and efficient. Whether you need guidance on maintaining your wellness routine or understanding what screenings are pertinent to you, using this form can help you stay on track and manage your healthcare more effectively.

Healthcare Wellness 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)

 

 

 

 

 

 

 

Vaccine review (see what shots you

 

 

may be due for)

 

 

Annual wellness visit/

 

Date done

 

routine physical

 

 

 

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

 

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

Form Characteristics

Fact Name Fact Description
Purpose The Healthcare Wellness form is designed to help individuals track preventive care and health screenings.
Annual Checkup It is recommended to have an annual wellness visit to discuss health needs and screenings with a primary care provider.
Flu Shot Annual flu shots are recommended during flu season as a preventive measure against influenza.
Recommended Screenings The form outlines various recommended screenings, including cholesterol tests and cancer screenings based on age and sex.
Mammogram Guidelines Women should start mammogram screenings at age 45, with options to switch to biennial screenings at age 55.
Risk Assessment It encourages individuals to assess risk factors such as falls or bladder control issues.
Discussion Topics There is space to write down important discussion topics for the appointment, including medications and mental health.
PCP Coordination Listing specialists helps the primary care provider coordinate overall patient care effectively.
Regulatory Body The recommendations align with guidelines from health authorities such as the American Cancer Society.
Customer Service Members can contact Customer Service for assistance with scheduling appointments and understanding coverage.

Guidelines on Utilizing Healthcare Wellness

Completing the Healthcare Wellness form is a straightforward process. This form is essential for preparing for your next medical appointment. Follow the steps outlined below to gather the necessary information for effective communication with your primary care provider.

  1. Personal Information: Start by entering your full name, date of birth, and contact information at the top of the form.
  2. Annual Care Checklist: Review the list of recommended preventive care services. Check off the services you have completed within the last year and note the dates.
  3. Special Care: For tests and treatments advised by your PCP, check the services you have undergone and write down the date.
  4. Medications: Record all prescriptions, over-the-counter medications, and supplements you are currently taking. Note any difficulties you have experienced taking them.
  5. Health Evaluations: In the section for mental and physical health, describe any issues or concerns you have been facing. Mention any mental health challenges or physical pain that impacts your daily activities.
  6. Additional Concerns: Address any worries regarding bladder control and physical activity. Select options that apply to your situation.
  7. Care Team: List all specialists or other healthcare providers you see. This helps in coordinating your care more effectively.
  8. Your Questions: Write down any questions you have for your PCP about your medications, test results, or follow-up appointments.
  9. Final Review: Go over all sections to ensure all information is filled out accurately. Correct any mistakes before submitting.

What You Should Know About This Form

What is the purpose of the Healthcare Wellness form?

The Healthcare Wellness form, specifically the 2022 Annual Care Checklist, serves as a guide for maintaining your health. It helps you keep track of important preventive care services and screenings recommended by your primary care provider (PCP). By utilizing this checklist during your appointments, you can ensure that you are up-to-date on necessary tests and vaccinations, ultimately catching potential health issues early.

What preventive care services are recommended in the Healthcare Wellness form?

This form suggests various preventive care services based on your age and health needs. Some services include annual wellness visits, flu shots, cholesterol screenings, Pap smears for women, and mammograms for women starting at age 45. Additionally, it covers checks for blood pressure and lifestyle habits, with a focus on issues like alcohol use and tobacco cessation. Having this checklist makes it easier to discuss these services with your PCP.

How can I prepare for my appointment using this form?

Preparation is crucial for making the most out of your appointment. Use the form to jot down your current medications, including prescriptions and supplements. Be ready to ask questions about your medications, potential side effects, and any cheaper alternatives. Also, list any specialists you see, which will help your PCP organize your overall healthcare. Finally, take notes during your visit about recommendations and follow-up actions from your PCP.

What should I discuss regarding my mental health during the appointment?

Your mental health is just as important as your physical health. Be open with your PCP about any feelings of sadness, sleep difficulties, or challenges with memory and planning. Sharing this information helps them understand the full picture of your well-being. If you feel comfortable, consider discussing coping strategies or any changes in your life that might affect your mental health.

What if I have specific health concerns or questions about my care?

Specific health concerns should be addressed with your PCP. Whether it relates to bladder control issues, risk of falls, or pain affecting your daily life, bring these up during your appointment. It’s your opportunity to voice any worries and to feel understood. Prepare in advance by noting your symptoms or concerns so that your PCP can offer tailored advice and care options.

What actions can I take if I have questions after my appointment?

If queries arise after your visit, do not hesitate to reach out to Customer Service on the number located on your member ID card. They can assist you with questions about scheduling future appointments, understanding your care options, or clarifying your coverage details. Regular communication ensures you continue getting the care you need, right when you need it.

Common mistakes

Completing the Healthcare Wellness form is an essential step in maintaining health, but many individuals overlook key details. One common mistake is failing to update medication lists. Patients should ensure all medications, including prescriptions, over-the-counter drugs, and supplements, are current. Missing even one medication can lead to misunderstandings in treatment or potential adverse reactions.

Another frequent error is neglecting to discuss mental and physical health openly. Many people feel uncomfortable sharing their concerns about mental health, which can result in untreated issues. It's vital to communicate feelings, challenges, and experiences that may impact overall well-being. Additionally, neglecting to mention significant physical health challenges can hinder a physician’s ability to provide optimal care.

A third common misstep involves not preparing adequately for discussions about tests and treatments. Patients should arrive with questions regarding any ordered tests, such as when results will be available and whether a follow-up appointment is necessary. Failing to ask these questions can lead to uncertainty and missed opportunities for timely intervention.

Some individuals also make the mistake of underestimating the importance of lifestyle screenings. This may include not addressing alcohol use, tobacco reliance, or dietary habits with their Primary Care Provider (PCP). These lifestyle factors are crucial in preventive care and should be discussed openly for a comprehensive health evaluation.

Another oversight is the lack of detail in listing other healthcare providers. Patients often forget to mention specialists they see, which can impede the PCP's ability to provide coordinated care. Clear communication about every provider involved in one's healthcare journey is necessary for achieving the best outcomes.

Finally, individuals frequently miss the opportunity to address unique health concerns, such as bladder control issues or the risk of falls. Not discussing these topics can prevent the PCP from offering appropriate assessments and recommendations. Patients should take the time to consider all relevant health information and bring it forward when filling out the form and attending appointments.

Documents used along the form

The Healthcare Wellness form serves as a comprehensive tool for individuals to track their preventive care. Along with this document, several other forms and documents are frequently used to enhance health monitoring and communication between patients and healthcare providers. Here are some common ones:

  • Patient Health Questionnaire (PHQ-9): This is a widely used screening tool for depression. Patients answer questions about their mood and behaviors over the past two weeks, allowing healthcare providers to assess mental health needs accurately.
  • Medication List: A detailed list of all medications a patient is currently taking, including prescription, over-the-counter drugs, and supplements. This document helps prevent drug interactions and ensures providers have all necessary information for safe treatment.
  • Advance Directive: This legal document outlines a person's wishes regarding medical treatment in situations where they are unable to communicate. It can specify preferences for life-sustaining treatments and appoint a healthcare proxy.
  • Family Medical History Form: This document records health conditions and diseases that run in a patient’s family. It is crucial for assessing hereditary risks and making informed healthcare decisions.
  • Immunization Record: This form tracks vaccinations received by the patient. It is important for ensuring that individuals stay on schedule with required vaccines and for documenting vaccination status in school or employment settings.
  • Referral Form: When a primary care provider refers a patient to a specialist, a referral form is often completed. It includes information about the patient’s medical history and the reason for the referral, ensuring continuity of care.

Incorporating these documents into healthcare practices can improve patient experiences and outcomes. Each plays a vital role in communication and care coordination within the healthcare system.

Similar forms

  • Patient Assessment Form: This document collects comprehensive health information from patients, similar to the Healthcare Wellness form, to help healthcare providers make informed decisions about care options and preventative measures.
  • Preventive Care Checklist: This checklist outlines essential screenings and immunizations, mirroring the goal of the Healthcare Wellness form while emphasizing the importance of preventive health measures.
  • Health Risk Assessment: Designed to evaluate a person's health risks, this form gathers data that aligns with the screening sections of the Healthcare Wellness form, aiming to identify potential health concerns early.
  • Annual Physical Examination Record: This record documents the findings from a physical exam, akin to the various health evaluations included in the Healthcare Wellness form, ensuring continuity in patient care.
  • Medication Reconciliation Form: This document lists all medications a patient is taking, similar to the medication section of the Healthcare Wellness form that encourages patients to discuss their prescriptions with their primary care provider.
  • Immunization Record: This form tracks vaccinations, paralleling the vaccine review section of the Healthcare Wellness form and highlighting the importance of maintaining up-to-date immunizations.
  • Chronic Disease Management Plan: This plan outlines monitoring and treatment strategies for chronic health issues, aligning with the focused health evaluations found in the Healthcare Wellness form for conditions like diabetes or hypertension.
  • Mental Health Screening Questionnaire: This questionnaire assesses mental well-being, similar to the mental health discussion prompts in the Healthcare Wellness form, which aim to foster open communication between patients and healthcare providers.

Dos and Don'ts

When filling out the Healthcare Wellness form, it's crucial to approach the task thoughtfully. Here are eight important things to do and avoid:

  • Do gather all relevant health information beforehand, including medications and previous test results.
  • Do be honest about your health conditions and lifestyle choices; this helps your healthcare provider assist you better.
  • Do ask questions if you don't understand something on the form or related to your health.
  • Do take your time to complete the form accurately to ensure the best care.
  • Don't rush through the form; incomplete or incorrect information may lead to issues during your appointment.
  • Don't skip sections. Every part of the form is designed to provide vital information to your healthcare team.
  • Don't hesitate to include any concerns, no matter how small they may seem.
  • Don't forget to keep a copy of the completed form for your own records.

By following these guidelines, you can help streamline your appointment and ensure you receive the best possible care.

Misconceptions

Understanding the Healthcare Wellness form can be tricky, and many common misconceptions may lead to confusion. Here, we clarify these misunderstandings so you can navigate your healthcare with confidence.

  • Misconception 1: The checklist is mandatory.
  • Many believe that completing the checklist is a requirement for their healthcare. In reality, it is a helpful tool designed to guide discussions with your primary care provider (PCP), not a mandatory document.

  • Misconception 2: All tests listed must be completed every year.
  • Not every test on the checklist is necessary annually. Some tests, like cholesterol screenings or mammograms, may be recommended on different schedules depending on individual health status.

  • Misconception 3: The Healthcare Wellness form provides specific medical advice.
  • The form is not a substitute for professional medical advice. It serves as a guideline to facilitate discussions with your PCP about your health needs.

  • Misconception 4: You can only discuss health issues noted in the form.
  • The form prompts you to bring important topics to light, but it is entirely appropriate to discuss other concerns during your appointment.

  • Misconception 5: The form automatically schedules your next appointment.
  • Completing the form does not mean your follow-up appointment is booked. It is up to you to schedule that with your provider.

  • Misconception 6: Completing the form ensures insurance coverage for all tests.
  • Insurance coverage may vary by plan. It is crucial to check with your insurance provider regarding coverage for specific screenings and tests.

  • Misconception 7: Everybody should get every vaccination listed.
  • Vaccination needs differ based on age, health conditions, and other factors. Your PCP will help determine which vaccinations are right for you.

  • Misconception 8: The Healthcare Wellness form is only for adults.
  • While many sections are geared towards adults, discussions about some aspects, like vaccinations or screenings for children, can also be included during health exams.

  • Misconception 9: Only your primary care doctor reviews the form.
  • Other healthcare providers, like specialists, can also refer to this form to understand your health history and better coordinate care.

  • Misconception 10: The form contains all the information you need about your health care.
  • The checklist is a useful starting point, but it’s essential to stay informed about overall health and any new recommendations that may arise.

By debunking these myths, you can approach your healthcare appointments feeling more prepared and informed.

Key takeaways

Understanding the importance of the Healthcare Wellness form is crucial for maintaining your health. This form serves as an essential tool for optimizing your preventive care appointments. Here are some key takeaways:

  • Bring the form to your appointment. Having the Healthcare Wellness form on hand allows for a structured discussion with your primary care provider (PCP).
  • Stay organized. Fill out the form completely before your appointment to ensure that all topics of concern are addressed.
  • Discuss preventive screenings. Make sure to go over which preventive care services may be relevant for you based on your age, gender, and medical history.
  • Review medications. List all medications you're currently taking, including over-the-counter drugs and supplements, to ensure clarity during your discussion with your PCP.
  • Be proactive about your mental health. The form prompts discussions about mental wellness, helping you address any challenges you may be experiencing.
  • Address physical health issues. Mention any ongoing pain or health concerns that might affect your daily life, so your PCP can provide tailored advice.
  • Identify any specialists. Listing specialists you see helps your PCP coordinate your overall care more effectively.
  • Follow up on tests. Inquire about any tests ordered during your visit, including when to expect results and the need for follow-up appointments.

Utilizing the Healthcare Wellness form ensures a comprehensive approach to your health. By actively engaging in your healthcare conversations, you empower yourself and pave the way for better health outcomes.