Wellness Program Intake Assessment (HRA/Whole-Person)

Date/Time: [Encounter date and time]

Encounter Type: [in-person / video / phone / questionnaire review]

Location: [Clinic or program site]

Author/Role: [Name, credentials, role]

Data Sources: [Patient self-report / standardized questionnaire(s) / chart review / external records / caregiver report / device or app data]

Interpreter/Accommodations: [Language, modality, and accommodations] (Only include if applicable; otherwise omit this field entirely.)

Consent for Sharing: [Consent status and any limitations for sharing with PCP, behavioral health, care management, program sponsor] (If not discussed, state "Not discussed.")

Reason for Visit / Patient Priorities

Referral Source & Primary Wellness Intent: [Referral source and concise statement of wellness intent]

Patient-Stated Priorities (1–3): [Priority 1]; [Priority 2]; [Priority 3] (Use the patient's own words when provided; include only items explicitly stated.)

Clinician Translation to Measurable Domains: [Brief mapping of patient priorities to measurable health domains and potential targets]

Health Risk Assessment

Self-Rated Health: [excellent / very good / good / fair / poor] | [Perceived drivers: energy, pain, mood, stress, sleep, finances, caregiving, other] | [Strengths and assets: supports, routines that work, motivation sources]. (If not assessed, state "Not assessed.")
Demographics & Context: [Age] | [Sex at birth] | [Gender identity] (Include if relevant; otherwise omit.) | [Household composition] | [Occupation and work schedule; note shift work if applicable]. (Use "Patient declined" for sensitive items not provided.)
Medical History: (Diagnosed conditions – problem list style with onset year when known) [Condition 1 (year)]; [Condition 2 (year)] | (Patient-reported concerns not yet evaluated) [Concern(s)] | (Surgical/procedural history) [Key procedures with year] | (Major hospitalizations) [Event(s) with year].
Family History: [First-degree cardiometabolic disease] | [Cancer patterns] | [Premature cardiovascular disease] | [Mental health or substance patterns] | [Hereditary risk flags impacting screening or counseling]. (If limited or unknown, state "Family history limited/unknown" and list any high-impact items known.)
Medications & Allergies: (Current prescriptions with dose/frequency if known) [List] | (Adherence concerns) [Yes/No with details if yes] | (OTC, supplements, vitamins, herbals) [List] | (Allergies/intolerances) [List]. Medication list reconciled: [yes / no / partial] with [source reconciled against].
Care Team & Access: [PCP] | [Key specialists] | [Behavioral health supports] | [Preferred pharmacy] | [Barriers to access: transportation, cost, availability, other] | [Approximate last visit dates if known].

Psychosocial & Behavioral Health

Depression Screen: [Tool name], [Date], [Score], [self-administered / staff-administered]. (If positive or clinically concerning: [Follow-up assessment performed] and [Disposition: referral / warm handoff / resources provided / safety planning].)

Anxiety Screen: [Tool name], [Date], [Score], [Administration mode]. (If not screened, briefly note rationale.)

Stress & Coping: [Stress level or scale if used] | [Major stressors] | [Coping strategies and protective factors].

Social Connection: [Frequency of loneliness or isolation] | [Primary social supports] | [Community involvement].

Tobacco/Nicotine: [never / former / current]. (If current: [Product(s)], [Quantity and frequency], [Duration], [Quit attempts], [Readiness to quit]. Document that cessation counseling was offered and referrals or resources discussed.)

Alcohol: [Screening tool], [Date], [Score]. (If positive: [Brief intervention provided] and [Referral options discussed].)

Other Substance Use: [Tool, date, result if screened]. (If not screened, note rationale: scope, setting, patient declined, or no referral pathway available.)

Nutrition: [Typical daily eating pattern] | [High-impact features: sugar-sweetened beverages, ultra-processed foods, fiber and produce intake] | [Food access constraints] | [One leverage point for change].

Physical Activity: [Days per week] | [Minutes per day of moderate-to-vigorous activity] | [Strength training: yes/no with frequency] | [Balance activities if older adult] | [Limitations: pain, dyspnea, time constraints, other].

Sleep: [Schedule] | [Total sleep time] | [Sleep quality] | [Insomnia symptoms] | [Snoring or witnessed apnea if relevant] | [Shift work impact if applicable].

(For any domain where the patient declined to answer, document "Patient declined" and note whether resources were offered if clinically indicated.)

Functional Status & Safety

ADLs: (Use: Independent / Needs some help / Dependent / Not assessed. Add brief narrative only for abnormalities.)

• Bathing: [Status]
• Dressing: [Status]
• Toileting: [Status]
• Transferring: [Status]
• Feeding: [Status]
• Grooming: [Status]

IADLs:

• Shopping: [Status]
• Food preparation: [Status]
• Phone use: [Status]
• Housekeeping: [Status]
• Transportation: [Status]
• Medication management: [Status]
• Finances: [Status]

Falls Risk: (Include for older adults or those with risk factors.) [Falls in past year: yes/no with number] | [Injuries] | [Unsteadiness or fear of falling] | [Assistive devices]. (If positive, document follow-up plan: strength/balance referral, medication review request, home safety suggestions.)

Hearing & Vision: [Self-reported hearing difficulty and hearing aid use] | [Vision issues] | [Last eye exam if known].

Cognitive Concerns: [Patient or caregiver concerns] | [Brief objective observations]. (If concern identified, note next steps: formal screening, PCP referral, medication review.)

Social Needs Screen

Screening Approach: [universal / targeted]. (Document that interpersonal safety questions were asked privately.)

Results: Housing instability: [Yes / No]; Food insecurity: [Yes / No]; Transportation barriers: [Yes / No]; Utility needs: [Yes / No]; Interpersonal safety: [Safe / Concerns identified / Patient declined].

Actions & Resources: [Resources provided, referrals placed, warm handoff, education]. (If referral pathways are not available, note "resource limitation" or "deferred – no referral pathway available.")

Baseline Measures

Vitals: Height: [value]; Weight: [value]; BMI: [value]; Blood pressure: [value] (Note measurement context if atypical.); [Other vitals as appropriate].

Labs: [Test name] – [Date], [Result with units], [Source: internal / external], [Fasting status if applicable]. (Repeat for each available lab. If none available, state "No baseline labs on file" and note intended actions in Plan.)

Preventive Care Status: [Immunizations snapshot] | [Age-appropriate screening status: breast, cervical, colorectal, lung, other as applicable] | [Overdue items].

Risk Summary

Top Risks (ranked):

• [Risk 1 – brief rationale]
• [Risk 2 – brief rationale]
• [Risk 3 – brief rationale]

Key Strengths: [Motivation, supports, existing routines, prior success].

Care Gaps: [Missing baseline measures, overdue preventive items, needed follow-up or specialist input].

Red Flags & Immediate Actions: [Minimal necessary detail of concern and action taken: safety planning, urgent referral, emergency evaluation]. (If none, state "None identified.")

Personalized Wellness Plan

Priority 1: [Priority area in patient's words or concise label]

Goals (SMART): [Baseline behavior or measure] → [Specific goal: what, how often, how much] | [Start date] | [Reassessment date] | [Tracking method].

Readiness: [Stage of change if assessed] | Confidence: [0–10] | Importance: [0–10] | Barriers: [List] | Supports: [List].

Education & Counseling: [Topics discussed and patient response].

Referrals & Resources: [PCP, dietitian, behavioral health, PT or exercise program, sleep evaluation, community resources, digital tools]. (If program cannot place referral, document as recommendation and specify who will place it.)

Follow-up: [Interval and modality for next contact] | [Specific measures to reassess].

Priority 2: [Priority area]

(Repeat structure above. Include only if additional patient-identified priorities were addressed.)

Priority 3: [Priority area]

(Repeat structure above. Include only if applicable.)

Overall Follow-up Plan: [Next contact timing and modality] | [Planned data to collect] | [Coordination with PCP or other team members].