Free CMS-Compliant health risk assessment template

Key Takeaways

A health risk assessment questionnaire is a structured screening tool that identifies patient health risks, chronic conditions, mental health concerns, and lifestyle factors, and it is a required component of the Medicare Annual Wellness Visit.

CMS mandates the HRA as part of the AWV under HCPCS codes G0438 (initial) and G0439 (subsequent), covering five required domains: demographics, self-assessed health status, psychosocial risks, behavioral risks, and functional status.

The questionnaire must assess chronic conditions, mental health (including depression and anxiety screening), medication use, functional ability, and advance care planning; missing any domain can trigger compliance issues and missed clinical insights.

Practice management software like Pabau lets practices deploy HRAs online, auto-populate patient records, and trigger follow-up care actions, reducing manual data entry and keeping HRA completion consistent before appointments.

Medicare requires a completed health risk assessment before a practice can bill for the Annual Wellness Visit. This free health risk assessment questionnaire template covers all five CMS-required domains, so practices can meet the documentation requirement and get reimbursed without building a form from scratch.

The template arrives as a print-ready PDF. Convert it into a digital form within Pabau to collect responses online and route them straight into the patient’s record.

What is a health risk assessment questionnaire?

A health risk assessment questionnaire is a structured clinical screening tool that gathers comprehensive information about a patient’s current health status, medical history, risk factors, and lifestyle habits. The form identifies potential health risks, enables clinicians to develop personalized treatment plans, and establishes a baseline for ongoing monitoring and care coordination.

Unlike a general health check, a health risk assessment questionnaire goes deeper. It systematically evaluates physical health, mental health, psychosocial stressors, behavioral risks, and functional capability. The result is a comprehensive risk profile that informs clinical decision-making and prevents missed care.

Why practices use HRAs

• Medicare compliance: CMS requires an HRA as part of the Annual Wellness Visit (AWV) for Medicare Part B beneficiaries.
• Early risk detection: Identifies chronic conditions, mental health concerns, and social determinants of health before they escalate.
• Preventive planning: Data drives the development of a personalized prevention plan (PPP) tailored to the patient’s specific risk profile.
• Baseline documentation: Creates a standardized record for longitudinal patient care, ensuring continuity across appointments and care transitions.
• Care coordination: Surfaces information (medications, allergies, functional limitations, advance directives) that other specialists or care teams need to know.

Why the HRA matters for the Medicare Annual Wellness Visit

The Medicare Annual Wellness Visit (AWV) is a yearly preventive appointment covered under Medicare Part B. CMS explicitly requires a health risk assessment as a mandatory component. Practices cannot bill for an AWV (HCPCS G0438 for initial, G0439 for subsequent visits) without completing and documenting an HRA.

The HRA is not optional paperwork; it is the clinical and reimbursement foundation of the AWV. Practices that skip or incomplete the HRA risk claim denials, audit exposure, and missed opportunities to identify preventable health risks in their Medicare patient population.

• G0438 (Initial AWV): Covers a new Medicare beneficiary’s first wellness visit, including comprehensive HRA and personalized prevention plan.
• G0439 (Subsequent AWV): Covers follow-up wellness visits for established Medicare beneficiaries; HRA is still required even if condensed.
• Documentation requirement: The HRA must be documented in the patient’s medical record and referenced in the visit note to justify reimbursement.
• Frequency: Medicare allows one AWV per 12-month period per beneficiary.

For primary care practices, managing HRA workflows efficiently is critical to capturing this recurring revenue stream while maintaining quality care.

Core CMS-required domains in an HRA

CMS specifies five mandatory domains that every health risk assessment questionnaire must cover. Missing any one of these domains means the HRA does not meet the regulatory standard, potentially invalidating the AWV billing and leaving clinical risks unaddressed.

Here are the five CMS-required HRA domains:

Each domain contributes to a complete clinical picture. Patient portals allow self-service HRA completion, reducing clinician time while ensuring comprehensive data capture before the visit.

What each section of the template should include

A well-designed HRA template organizes questions into logical sections that map to the five CMS domains. Here is what each section should contain:

Patient information and demographics

Collect name, date of birth, contact information, insurance details, emergency contact, race/ethnicity, and family composition. This section establishes the demographic foundation required by CMS and enables care coordination.

General health and medical history

Ask about overall health status perception, past medical diagnoses, current chronic conditions (diabetes, hypertension, heart disease, cancer, arthritis, etc.), hospitalizations, surgeries, and family history of disease. Include recent blood pressure monitoring readings if the patient already has them on file. This captures the self-assessed health status and establishes clinical context.

Medications and allergies

List all current medications (name, dose, frequency), over-the-counter drugs, supplements, and document all drug allergies and adverse reactions. This is critical for medication management and safety and must be reviewed at every visit.

Mental health and psychosocial screening

Screen for depression (e.g., PHQ-2 or similar), anxiety, substance use (tobacco, alcohol, drugs), social support, housing stability, and safety concerns (domestic violence, abuse). Use validated screening tools where appropriate, and route positive findings into your mental health EMR for follow-up documentation; many HRAs include a brief depression screen as a minimum standard.

Lifestyle and behavioral factors

Document tobacco and alcohol use, exercise frequency and type, dietary habits, sleep quality, stress level, and sexual history (if relevant to primary care). Medicare reimburses annual alcohol misuse screening separately under G0442, so flag positive responses for that visit too.

Functional status and activities of daily living (ADL)

Ask about ability to perform self-care activities (bathing, dressing, toileting, eating), mobility (walking, climbing stairs), instrumental ADLs (cooking, shopping, managing finances), and use of assistive devices. This identifies functional decline and informs holistic care planning.

Advance care planning

Ask whether the patient has advance directives, a durable power of attorney for health care, or wishes regarding end-of-life care. Document any preferences or spiritual/religious considerations that should guide clinical decision-making.

Sample HRA questions by domain

Below is a table of evidence-based sample questions organized by CMS domain. Practices can adapt these to their population and clinical context:

CMS does not prescribe exact wording; these examples reflect best practices from clinical literature and government guidance. Adapt them to match your patient population and clinical workflow.

How to use HRA results in clinical practice

Completing the HRA is only the first step. The value emerges when clinicians interpret results, score risk domains, and translate findings into a personalized prevention plan and follow-up actions.

Step 1: Review and score responses

Read the patient’s responses before the appointment. Flag any “red flag” answers (e.g., depression screening score above threshold, reported substance use, functional decline, safety concerns). Note missing or inconsistent answers and plan to clarify during the visit.

Step 2: Conduct focused clinical assessment

During the AWV, explore HRA findings through conversation and targeted examination. A patient reporting functional limitation should trigger a gait assessment or fall-risk evaluation. Positive depression screening warrants further mental health assessment.

Step 3: Identify and document health risks

Document all identified health risks in the medical record. CMS requires that the AWV visit note include a documented health risk assessment and a statement of identified risks, which supports the claim submitted on the CMS-1500 form.

Step 4: Create a personalized prevention plan

Based on identified risks and patient priorities, develop a written prevention plan. It should specify the following:

• Preventive services recommended (vaccinations, screening tests)
• Treatment decisions for chronic conditions
• Lifestyle modification goals
• Follow-up appointments
• Referrals to specialists or community resources

Step 5: Execute follow-up actions

Document the prevention plan in the patient’s clinical record, schedule necessary follow-up appointments and testing, and close referral loops. Practices using digital form capture can auto-populate patient records and trigger automated reminders for preventive services.

Integrating the HRA into your practice workflow with Pabau

Paper-based HRAs create friction: patients forget to complete them, clinicians re-enter data manually, and follow-up actions are often overlooked. A digital HRA workflow removes this friction. Practices using Pabau’s digital forms can deploy HRAs online, capturing responses directly into the patient’s clinical record before the appointment.

Once the HRA is submitted, Pabau’s automated workflows can trigger clinician alerts for high-risk findings, schedule follow-up appointments, auto-populate the visit note, and send post-appointment prevention reminders to the patient. This workflow ensures every CMS-required domain is documented, reduces clinician time on data entry, and improves patient outcomes.

Best practices for HRA administration

A few operational tips to improve HRA completion rates and data quality:

• Send the form before the visit: Email or SMS the HRA to patients at least 48 hours before their appointment, with instructions to complete and return it. Early completion saves time during the visit.
• Use a patient portal: Patient portals simplify form submission and reduce lost paperwork, so responses go directly into the medical record.
• Review responses before the appointment: Allocate 5 minutes before the visit to scan the HRA, flag high-risk findings, and plan your assessment accordingly.
• Document clinical response: Write a brief note in the medical record summarizing identified risks and your clinical response (e.g., “Patient endorses depressive symptoms; mental health referral recommended”).
• Automate follow-up: Use automated reminders to prompt preventive services completion (vaccinations, screening tests) after the AWV.

Conclusion

A downloadable template is the starting point, but the payoff comes from administering the HRA consistently, scoring it, and acting on the results.

To stay compliant, every Annual Wellness Visit needs to document all five required domains — check the official Medicare Annual Wellness Visit guidance for the current minimum elements before you finalize your form.

Pabau lets you deliver the questionnaire as a digital intake form, capture responses in the patient record, and trigger follow-up tasks automatically — so the HRA feeds straight into the prevention plan instead of sitting in a paper file. To see how it fits your practice’s AWV workflow, book a demo.

Continue your research

HCPCS code G0439 — how to bill the subsequent Annual Wellness Visit.

Medical records management — keep HRA results and prevention plans in one patient chart.

Automated workflows — trigger reminders and follow-up tasks after each assessment.

GP practice software — run preventive visits end to end for primary care patients.

Frequently asked questions about the health risk assessment questionnaire