Medicare Annual Wellness Visit Page 3
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6Name_____________________________________________________
Date______________
Vaccines
Date
Frequency
Pneumonia vaccine
__________________________
age 65
(repeat 10 yrs)
Zostavax (shingles vaccine) __________________________
once
Flu vaccine
__________________________
Yearly
Tetanus/diphtheria
__________________________
every 10 years
Screenings
Date
Frequency
Mammogram (females)
__________________________
Yearly
Colonoscopy
__________________________
every 1-10 years
PSA (males)
__________________________
Yearly
EKG
__________________________
Yearly if High BP
Cholesterol
__________________________
6mo - yearly
Bone Density
__________________________
Every 2 years
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