Personalized Prevention Plan (AWV)

Personalized Prevention Plan (Annual Wellness Visit)

Patient: [Full name, date of birth] | Date: [Encounter date]

Provider: [Clinician name, credentials] | Clinic: [Practice name, phone number]

About This Plan

This plan is based on your wellness visit today. It lists the preventive care and screenings recommended for you over the next few years. It is not a full physical exam and does not address urgent symptoms.

Your Health Priorities

(List 3–5 priorities based on identified risk factors, care gaps, or conditions. Use person-first, non-stigmatizing language. If no new risks or care gaps were identified, replace the list with: "You are up to date on key preventive care at this time. Keep up the good work." If any risk factor status is unknown, label it as "Unknown" and add a step to confirm at the next visit. Do not infer facts that are not documented.)

• [Priority title]
  • What we found: [Brief description of finding or status, or "Unknown" if not documented]
  • Why it matters: [One sentence on health impact or goal]
  • Your next steps: [Specific patient actions with timing]
  • Clinic actions: [Orders, referrals, or follow-ups with timing]

(Repeat the above format for each additional priority, up to 5 total.)

Prevention & Screening Schedule

(Include only services applicable to this patient's age, sex, and risk profile. Omit entire categories if not applicable. Use absolute dates when possible. For unknown histories, write "Not documented" and include next steps. Use "Discuss" for shared decision-making items. Use "Declined" with brief nonjudgmental note if patient declined.)

Service	Last Done	Next Due	How to Schedule
Cancer Screenings
[Screening name]	[Date / Not documented]	[Date / Discuss / Declined]	[Scheduling instructions]
Heart & Metabolic Health
[Screening or monitoring service]	[Date / Not documented]	[Date or timeframe with target date]	[Scheduling instructions]
Immunizations
[Vaccine name]	[Date / Not documented]	[Date / Eligible today / Discuss]	[Pharmacy / Clinic / Other location]
Other
[Other preventive service]	[Date / Not documented]	[Date or timeframe]	[Scheduling instructions]

(Add rows as needed within each category. Remove entire category sections if not applicable to this patient.)

Follow-Up & Contact Information

• Next Annual Wellness Visit: [Target month and year, approximately 12 months from today]
• Upcoming appointments: [Date, time, purpose, and location for each] (If none scheduled, write: "Clinic will contact you within [timeframe] to schedule" or provide self-scheduling instructions.)
• Questions or updates: Contact [clinic phone number] or use [patient portal name]. Business hours: [hours].
• After-hours care: Call [after-hours number] for urgent needs that cannot wait until business hours. (Omit if not applicable.)

Safety: Call 911 or go to the nearest emergency department for life-threatening symptoms like chest pain, trouble breathing, severe bleeding, or sudden confusion. For urgent but non-emergency concerns, call the clinic or after-hours line.