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Annual Wellness Questionnaire - Free Healthcare Template | ZenBuild | ZenBuild

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Annual Wellness Questionnaire

Gathers lifestyle, preventive care, and health status information for annual wellness visits.

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Annual Wellness Questionnaire

Gathers lifestyle, preventive care, and health status information for annual wellness visits.

Full Name*

Date of Birth*

Do you currently smoke or use tobacco products?*

YesNoFormer smoker

How often do you exercise per week?*

How would you describe your diet?*

ExcellentGoodFairPoor

Preventive screenings completed in the past year

Blood pressure checkCholesterol testBlood glucose testDental examEye exam

Rate your overall health this past year*

Any new health concerns or questions for your provider?

Template Details

CategoryHealthcare

IndustryHealthcare

Fields8

Uses0

Views1

healthcarewellnessannualpreventivequestionnaire