Components of an Annual Wellness Exam
An annual wellness exam should include a comprehensive medical history, physical examination, laboratory testing, preventive screenings, immunization updates, and personalized health planning to identify and address risk factors for disease. 1
Medical History Components
Personal History
- Complete review of medical history and current health status 1
- Review of previous diagnoses, treatments, and hospitalizations 2
- Medication review (prescription, over-the-counter, supplements) 2
- Allergies and medication intolerances 2
- Family history of diseases, particularly first-degree relatives 2
- Surgical history 2
Lifestyle Assessment
- Dietary patterns and nutritional status 1
- Physical activity habits and sleep behaviors 2
- Tobacco, alcohol, and substance use 2
- Stress levels and coping mechanisms 1
Social Determinants of Health
- Social support network 2
- Housing stability and transportation access 2
- Food security and financial stability 2
- Community safety 2
- Advanced care planning and surrogate decision maker identification 2
Physical Examination Components
Vital Signs
- Blood pressure measurement 2
- Heart rate and respiratory rate 2
- Temperature 2
- Height, weight, and BMI calculation 2
Systems Examination
- Cardiovascular examination (heart sounds, pulses) 2
- Pulmonary examination 2
- Abdominal examination 2
- Skin examination (lesions, rashes, concerning moles) 2
- Neurological assessment (reflexes, sensory function) 2
- Musculoskeletal assessment (joint function, strength) 2
- Vision and hearing screening 2
- Oral cavity examination 2
- Lymph node examination 2
- Thyroid examination 2
Gender-Specific Examinations
- For women: breast examination, pelvic examination when indicated 2
- For men: testicular examination, prostate examination when indicated 2
Laboratory Testing
Basic Screening Tests
- Complete blood count (CBC) 2
- Comprehensive metabolic panel 2
- Lipid profile (total cholesterol, LDL, HDL, triglycerides) 2
- Urinalysis 2
- Hemoglobin A1C or fasting glucose (for diabetes screening) 2
Additional Tests Based on Risk Factors
- Thyroid-stimulating hormone (TSH) 2
- Vitamin B12 levels (especially if on metformin) 2
- Vitamin D levels when indicated 2
- Liver function tests 2
- Kidney function tests (eGFR, albumin-to-creatinine ratio) 2
Cancer Screenings (Age-Appropriate)
- Breast cancer: mammography for women (annually starting at age 40) 2
- Colorectal cancer: options include colonoscopy every 10 years, flexible sigmoidoscopy every 5 years, or annual fecal occult blood testing starting at age 50 2
- Cervical cancer: Pap test according to age-appropriate guidelines 2
- Prostate cancer: discussion about PSA testing for men over 50 2
- Skin cancer screening 2
Immunization Review and Updates
- Influenza vaccination (annual) 2
- Tetanus-diphtheria-pertussis (Tdap) status 1
- Pneumococcal vaccination status 2
- Hepatitis B vaccination (especially for people with diabetes) 2
- COVID-19 vaccination status 2
- Other age-appropriate vaccinations 1
Risk Assessment and Preventive Planning
- Cardiovascular risk assessment 1
- Diabetes risk assessment 1
- Falls risk assessment (especially for older adults) 1
- Depression, anxiety, and mental health screening 2
- Cognitive assessment (for adults 65 and older) 2
- Substance use disorder screening 2
- Domestic violence screening 1
Health Promotion and Education
- Lifestyle modification guidance (diet, exercise, stress management) 1
- Smoking cessation counseling when applicable 2
- Weight management strategies 2
- Disease prevention strategies 1
- Self-care education 1
Documentation and Follow-Up Planning
- Written summary of findings 2
- Personalized prevention plan 1
- Goal setting for health improvement 2
- Referrals to specialists as needed 1
- Scheduling of follow-up visits and future screenings 1
Common Pitfalls to Avoid
- Focusing too much on the computer screen instead of the patient 1
- Failing to address emotional aspects of health 1
- Not allowing sufficient time for patient concerns 1
- Overlooking social determinants of health 1
- Missing opportunities for preventive care 1
- Ordering unnecessary tests that aren't evidence-based 3
While many patients expect a comprehensive annual physical examination 4, it's important to focus on evidence-based screenings and assessments that will have the greatest impact on reducing morbidity and mortality rather than performing every possible test.