Adult Annual Preventive Visit (Physical) Note

Date/Time: [Encounter date and time]

Location: [Clinic/site name]

Clinician: [Clinician name, credentials]

Patient Name: [Full name]

DOB: [DOB]

MRN: [MRN]

Source of History: [patient / caregiver / chart review] (Note if interpreter used and language; note if records limited)

Reason for Visit

[Prevention-oriented reason for visit] (Brief statement such as "Annual preventive exam and health maintenance review." Optionally include patient-stated priorities or agenda.)

Problem-Oriented Concerns (Separately Documented)

(Include this subsection only if a separately billable problem-focused concern was addressed; omit entirely otherwise.)

• Chief Complaint: [Problem-focused concern]
• HPI: [Focused history for problem-oriented concern]

Interval History

[Interval events since last preventive visit] (Summarize hospitalizations, ED/urgent care visits, new diagnoses, surgeries, medication changes by other clinicians, and major life changes affecting health. State last preventive visit date if known; if unknown, state explicitly. Do not use symptom-driven HPI format here.)

Problem List Review

• [Active problem]: [Stable / Requires separate management today] (Note preventive implications if applicable)
• [Surgical history summary] (Include if relevant to prevention or screening intervals)

Family History

[Risk-relevant family history] (Document first-degree relatives with premature CVD, hereditary cancer patterns—breast/ovarian, colorectal, prostate, melanoma—and conditions altering screening intervals; include relationship and age at diagnosis. State "Limited information" or "Unknown" if applicable rather than leaving blank.)

Social History

• Tobacco: [Never / Former (quit date) / Current] [Type and quantity]
• Alcohol: [Pattern and quantity]
• Other substances: [Type, frequency] (Include only if discussed)
• Physical activity: [Type, frequency, duration]
• Diet: [General pattern]
• Sleep: [Duration/quality]
• Occupation/exposures: [Role; relevant exposures] (Include if relevant)
• Sexual and reproductive health: [Sexual activity and partners; contraception/pregnancy intention; menstrual/menopause status] (Include items relevant to screening decisions; use neutral language)

Medications and Allergies

Medication Reconciliation: [Completed / Partially completed]

• [Medication: name, dose, route, frequency] (Include prescriptions, OTCs, and supplements; note adherence concerns or side effects if discussed)

Allergies: [Drug/agent: reaction type] (Specify anaphylaxis vs rash vs intolerance when known; state "No known drug allergies" or "Unknown" explicitly if applicable)

Health Maintenance Review

(For each applicable domain, document: last completed with date and result summary, current status [up to date / due / overdue / not indicated / declined / deferred], and plan. Include brief rationale for risk-based decisions. Include only domains relevant by age, sex, and risk factors.)

• Blood pressure and cardiovascular risk:
  • Blood pressure screening: [Last date/result]; [Status]; [Plan]
  • Lipids: [Last panel date/result summary]; [Status]; [Plan]
  • ASCVD risk (10-year): [Risk %] (Reference calculator and inputs)
• Diabetes screening: [Last A1c or fasting glucose date/result]; [Status]; [Plan]
• Colorectal cancer screening: [Modality, date, result]; [Status]; [Plan with interval]
• Cervical cancer screening: [Cytology/HPV date/result]; [Status]; [Plan] (Note hysterectomy status if relevant)
• Breast cancer screening: [Last mammogram date/result]; [Status]; [Plan]
• Lung cancer screening (preference-sensitive): [Pack-years; quit date if former]; [Eligibility]; [SDM discussion: benefits/harms reviewed, patient values/preference, decision reached]; [Plan]
• Prostate cancer screening (preference-sensitive): [Risk factors]; [SDM discussion: options/benefits/harms reviewed, patient preference, decision reached]; [Plan]
• HIV screening: [Last test date/result]; [Status]; [Plan]
• Hepatitis C screening: [Last test date/result]; [Status]; [Plan]
• Depression screening: [Tool, score, date]; [Status]; [Plan]
• Alcohol misuse screening: [Tool, result, date]; [Status]; [Plan]
• Osteoporosis screening: [DEXA date/result or risk-based indication]; [Status]; [Plan]
• Vision/hearing/dental: [Last routine care]; [Status]; [Referral/Plan]
• Other risk-based screenings: [STIs, hepatitis B, AAA, skin cancer, etc. as applicable]; [Status]; [Plan]
• Patient-requested tests not guideline-supported: [Request]; [Counseling and rationale]; [Decision] (Include only if applicable)

Immunizations

Status: [Up to date / Due / Overdue / Deferred] (Source: [patient report / registry / prior records])

Recommended today: [Vaccines due with rationale]

Vaccines Administered

(Include only if vaccines given today; omit entirely otherwise)

• [Vaccine name and dose]: [Route/site]; [Date]; Mfr/Lot: [Manufacturer, lot number]; VIS edition [date] provided [date]; Administrator: [Name, title]; Tolerance: [Tolerated well / Adverse reaction noted]

Review of Systems

(Optional; include only if performed. May reference intake questionnaire if ROS captured separately.)

• [ROS domain]: [Pertinent positives and negatives reviewed]

Vitals

• BP: [Value] (If elevated, repeat: [Repeat value])
• HR: [Value]
• Weight: [Value]
• Height: [Value]
• BMI: [Value] (Note trend or interpretation if abnormal)

Data Reviewed

• [Pertinent prior labs, imaging, or screening results with dates and source]
• [Risk calculator results with tool and inputs referenced]
• [Outside records: received / pending / requested]

Physical Examination

(Document only systems actually examined; do not template normal findings for unexamined systems. Tailor to age and risk.)

• General: [Appearance, distress, body habitus]
• HEENT: [Eyes, ears, nose, oropharynx; thyroid as indicated]
• Cardiovascular: [Rate/rhythm, murmurs, edema, pulses]
• Pulmonary: [Effort, breath sounds]
• Abdomen: [Contour, tenderness, masses]
• Skin: [Inspection; lesions if present]
• Musculoskeletal/Neurologic: [Strength, gait, balance; fall risk assessment for older adults]
• Extremities: [Findings]

Sensitive Examinations

(Include only if breast, pelvic, genital, or rectal exam performed or discussed; omit otherwise)

• Exam: [Breast / Pelvic / Genital / Rectal]: [Performed with findings / Deferred / Declined] (If declined, note rationale and alternative plan)
• Chaperone: [Offered and accepted (name/title) / Offered and declined / Not offered with rationale]
• Consent: [Obtained]

Assessment

• Preventive care and health maintenance: [Summary of screening status: up to date, due, overdue; key risk assessments]
• Risk factors requiring counseling: [List: tobacco use, elevated BMI, alcohol use, etc.]
• Stable chronic conditions reviewed: [Brief status only]
• Problems addressed separately: [Reference Problem-Oriented Concerns section] (Include only if applicable)

Plan

Preventive Care: [Screenings ordered with indication; referrals placed; immunizations given/recommended]

Counseling: (Include only topics actually discussed; omit others)

• [Topic]: [Brief assessment and patient goal]

Orders:

• Labs: [Ordered tests and indications]
• Imaging: [Ordered studies and indications]
• Vaccines: [Ordered/administered]
• Referrals: [Specialty and reason]

Follow-up: [Return interval for next preventive visit]; Results via [portal / phone]; Red flags for earlier return: [Symptoms warranting contact]

(If both preventive and problem-oriented services provided: Documentation supports each service as separately identifiable.)