What is the recommended approach to an adult annual wellness visit, including review of systems, functional and mental health assessment, preventive screening, immunizations, counseling, and management of abnormal findings?

Approach to the Adult Annual Wellness Visit

The adult annual wellness visit should include a structured assessment of vital signs and cardiovascular risk factors, mental health screening (particularly depression), substance use evaluation, age-appropriate cancer screening, immunization review, and targeted counseling on injury prevention, nutrition, and physical activity, with the specific components tailored to the patient's age and risk profile.

Core Components of Every Annual Visit

Vital Signs and Cardiovascular Assessment

• Measure blood pressure annually using proper technique with age-appropriate cuff size 1, 2
• Calculate and document body mass index (BMI) and waist circumference at each visit 1
• Obtain fasting lipid profile every 6-12 months in all adult patients, with consideration for more frequent testing (1-3 months) after starting medications that affect lipid metabolism 1
• Perform fasting glucose and/or HbA1c testing every 6-12 months, using an HbA1c threshold cutoff of 5.8% for screening purposes 1

Mental Health and Substance Use Screening

• Screen annually for depression using validated tools starting at age 11 and continuing through adulthood 2, 3
• This is critical because approximately 80% of individuals who need mental health treatment are not receiving care 1, 2
• Assess for substance use including tobacco, alcohol, marijuana, and other drugs using structured tools like the CRAFFT questionnaire for adolescents and young adults 2, 3
• Screen for anxiety, suicidal ideation, and self-harm behaviors, as suicide remains a leading cause of death in younger adults 2, 3

Immunization Review and Administration

• Verify and administer age-appropriate vaccinations including annual influenza vaccine 2, 4
• For adolescents and young adults: ensure completion of Tdap booster, HPV vaccine series (with strong recommendation emphasizing cancer prevention), and meningococcal conjugate vaccine 2, 3
• Use every visit as an opportunity to catch up on missed vaccinations, as concomitant administration of multiple vaccines reduces missed opportunities 4

Age-Specific Screening Recommendations

Cancer Screening

• Initiate colorectal cancer screening at age 50 in asymptomatic patients at average risk, with earlier screening for those with strong family history 1
• Perform annual mammography in women age ≥50 years, with consideration for initiation at age 40 based on individual risk assessment 1
• For women: perform cervical Pap smear annually after two normal tests documented during the first year following initial screening 1

Ophthalmologic Assessment

• Adults under 40 years: comprehensive eye examination every 5-10 years 1
• Ages 40-54: every 2-4 years 1
• Ages 55-64: every 1-3 years 1
• Age 65 or older: every 1-2 years 1
• Increased frequency is recommended for adults with risk factors such as diabetes, African American or Hispanic ethnicity (higher glaucoma risk) 1

Bone Health

• Perform baseline bone densitometry in postmenopausal women and men age ≥50 years, with periodic monitoring thereafter for those with risk factors for premature bone loss 1

Behavioral Health and Safety Counseling

Physical Activity and Nutrition

• Recommend at least 60 minutes of moderate to vigorous physical activity daily 1, 2, 3
• Counsel on healthy eating patterns, limiting sugar-sweetened beverages, and appropriate portion sizes 2, 3
• Assess dietary patterns and provide specific guidance on balanced nutrition 1

Injury Prevention

• Emphasize seatbelt use, helmet use for cycling and sports, and avoidance of distracted or impaired driving, as unintentional injuries are the leading cause of death in younger adults 2, 3
• Discuss firearm safety including safe storage practices when applicable to the household 2, 3
• Screen for involvement in or victimization from violence, including dating violence and abuse 2, 3

Sexual and Reproductive Health

• Provide comprehensive education on contraceptive methods including barrier devices, hormonal options, long-acting reversible contraception, and emergency contraception 3
• Screen sexually active patients annually for gonorrhea, chlamydia, and HIV 1, 3
• Initiate preconception counseling at puberty for all individuals of reproductive age, including folic acid supplementation discussion 3
• Screen for sexual violence and non-consensual encounters 2

Special Considerations for Adolescents and Young Adults

Confidentiality Requirements

• Provide mandatory confidential time alone with adolescent and young adult patients to address sensitive topics that directly impact morbidity and mortality 2, 3
• Explain confidentiality limits upfront (harm to self/others, abuse) to build trust 3
• Almost 1 in 4 adolescent boys report being too embarrassed to discuss important health issues when parents are present 2
• Approximately 58% of high school students report health concerns they wish to keep private from parents 2

Psychosocial Assessment

• Evaluate school or work performance, learning difficulties, peer relationships, and social functioning 2, 3
• Screen for bullying involvement or victimization 2, 4
• Assess sleep patterns and screen time, recommending 8-10 hours of sleep and limiting screen time before bedtime 3

Risk Factor-Specific Screening

Infectious Disease Screening

• Perform syphilis serology annually in patients at risk for sexually transmitted diseases, with more frequent testing for high-risk individuals 1
• Screen for hepatitis C annually in injection drug users and men who have sex with men 1
• Perform tuberculin skin test (TST) or interferon-gamma release assay (IGRA) at baseline and annually in patients at risk for tuberculosis 1

Digital Rectal Examination

• Consider performing annually in all adult patients to inspect for anal pathology and prostate abnormalities in men 1

Critical Pitfalls to Avoid

• Never conduct brief "sports physicals" instead of comprehensive examinations, as these lack psychosocial screening, confidentiality, and miss opportunities for early diagnosis and treatment of conditions causing significant morbidity and mortality 2, 4, 3
• Do not skip confidential time alone with adolescents and young adults, as this results in missed screening opportunities for risky behaviors 2, 3
• Never defer depression screening—it must be performed annually as a standard component of care 2, 3
• Do not delay HPV vaccination; provide a strong recommendation and normalize it by coadministering with other vaccines 2, 3
• Avoid skipping vision screening in children and adolescents, as undetected vision problems significantly impair learning and development 4
• Do not delay vaccination for minor illnesses such as mild upper respiratory infections, as studies show over 97% of children with mild illnesses produce appropriate antibody responses 4

Documentation and Follow-Up

Same-Day Treatment Opportunities

• When health problems are identified during the preventive visit, use the -25 modifier CPT code to allow same-day treatment of issues that would otherwise require another visit 1
• This represents an important window of opportunity for addressing problems in a timely manner and reducing risk of loss to follow-up 1

Coordination of Care

• Establish or maintain a medical home relationship that provides coordinated care 1
• Ensure comprehensive services are available through direct provision or appropriate referral 1
• Document all screening results, counseling provided, and follow-up plans clearly 1