Free Wellness Checklist for Patients Template
Wellness Checklist for Patients
Date: October 15, 2050
1. Health History Review
|
Health Factor |
Notes |
|---|---|
|
Last checked on October 5, 2050 |
|
Last checked on September 30, 2050 |
|
Last checked on September 25, 2050 |
|
No history of major diseases (heart, cancer) |
|
List of current prescriptions |
2. Preventive Health Screenings
|
Screening Type |
Date Last Done |
Next Recommended Date |
|---|---|---|
|
March 10, 2050 |
March 10, 2055 |
|
May 1, 2050 |
May 1, 2055 |
|
January 12, 2050 |
January 12, 2052 |
|
February 7, 2050 |
February 7, 2052 |
|
August 20, 2050 |
August 20, 2051 |
3. Lifestyle Habits and Wellness
|
Health Habit |
Current Status |
Suggested Improvement |
|---|---|---|
|
30 minutes walking |
Increase to 45 minutes |
|
Balanced meals |
Add more vegetables |
|
7 hours per night |
Aim for 8 hours |
|
6 cups of water |
Increase to 8 cups |
|
Yoga 2 times a week |
Add mindfulness practice |
4. Vaccinations
|
Vaccine Name |
Date Last Administered |
Next Due Date |
|---|---|---|
|
October 1, 2050 |
October 1, 2051 |
|
March 12, 2050 |
March 12, 2055 |
|
January 20, 2050 |
January 20, 2055 |
|
June 15, 2050 |
June 15, 2055 |
|
July 4, 2050 |
July 4, 2051 |
5. Mental and Emotional Health
|
Concern/Activity |
Notes |
|---|---|
|
Engaging in weekly counseling sessions |
|
No signs of depression at the moment |
|
Actively participating in support groups |
|
Needs improvement to reduce stress |
|
Practicing 10 minutes daily |
Next Steps:
Please schedule your next wellness checkup with [YOUR COMPANY NAME] at [YOUR COMPANY EMAIL] or call [YOUR COMPANY NUMBER] to book an appointment. Make sure to complete any outstanding screenings and consult with your healthcare provider for any updates to your care plan.
