Fillable Form 1: 2021 Annual Care Checklist (United Healthcare)

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Form 1: 2021 Annual Care Checklist (United Healthcare)

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Country of origin: US
File type: PDF

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Vaccine review (See what shots you
may be due for.)
2021 Annual Care Checklist
Nothing is more important than your health. That's why you can count
on UnitedHealthcare® to help you get the care you need, when you need it.
Take this checklist with you to your next appointment.
Good preventive care helps catch health issues early when they may be easier to treat. Have this checklist
handy at your next appointment. Tog
ether, you and your primary care provider (PCP) can decide which tests
and care services are right for you. Recommended preventive care services may include the following
1
:
Once a Year Date Done As Needed Date Done
Flu shot (every flu season)
Annual Wellness Visit/
Routine Physical
Date Done
Blood pressure check
Head-to-toe examination
Height, weight and body mass
index (BMI)
Lifestyle screening check such as
alcohol use, help quitting tobacco
and healthy eating, if applicable.
For People with Diabetes Date Done
As Recommended by Your PCP Date Done
Colon cancer screening
(for adults age 50 or older)
Hepatitis C virus infection
screening (for people at high risk
and a one-time test for adults born
between 1945–1965)
Mammogram screening
(every year starting at age 45;
starting at age 55 it can change to
every other year
)
2
Cervical cancer screening
(Pap smear) for women ages
21–65 years old
Cholesterol screening
Dental exam
Discuss screening and prevention
of osteoporosis
Eye exam
Fasting blood sugar screening
Hearing exam
See back for important topics to prepare for
your next appointment.
Exam to detect diabetes-related
issues for eyes
Exam to detect diabetes-related
issues for feet
Hemoglobin A1c (HbA1c)
LDL cholesterol
Statin medication, if clinically
appropriate
Urine test for protein
List any specialists or other providers you’re
seeing. This will help your PCP coordinate
your overall care.
Discuss any tests ordered during your
appointment. Ask:
Write down your prescriptions, over-the-counter
medications, supplements or vitamins you're
taking. Ask:
Discuss your level of physical activity with your
PCP. Ask if you should start, increase or maintain
your current exercise level.
Important topics to discuss with your PCP
Prepare for your appointment by filling in the information below. Then, write down any recommendations your
PCP may have about these topics and treatment options during your visit.
Medications Care Team
• Am I taking them correctly?
• Are there any side effects?
• Is there a lower-cost option?
Tests and Treatments
Physical Activity
• When can I expect results?
• Will I receive a follow-up call?
• Do I need a follow-up appointment?
Health Evaluations
Risk of Falls Bladder Control
I have had a fall I have problems with bladder control
I have problems with balancing or walking I have problems with leaking of urine
I don't have problems with balancing or falling I don't have bladder or urine leakage problems
Mental Health Physical Health
I feel calm and peaceful I have limitations with my regular daily activities
I have a lot of energy I have pain that interferes with my normal work
I feel sad or blue I have limitations with my social activities
I am having difficulty sleeping I don't experience any of the above
I don't experience any of the above
If you have questions, please call the Customer Service number on the back of your member ID card.
From scheduling your next checkup appointment to finding a provider, you can always count on us to
help you get the care you need, when you need it.
1
2
This is a list of suggested screenings. Coverage for these screenings (including how often they are covered) may vary by plan. If
you have questions about your specific benefits or coverage details, please call Customer Service at the number on the back of
your member ID card or check your Evidence of Coverage.
American Cancer Society, 2020.
©2021 United HealthCare Services, Inc. All rights reserved.
Y0066_SPRJ59133_20201214_C SPRJ59133
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Form 1: 2021 Annual Care Checklist (United Healthcare)

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Completed 15 October 2021

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