are well visits required

Catch Up on Well-Child Visits and Recommended Vaccinations

A happy child in a lion custome. Text: Let's play catch-up on routine vaccines

Many children missed check-ups and recommended childhood vaccinations over the past few years. CDC and the American Academy of Pediatrics (AAP) recommend children catch up on routine childhood vaccinations and get back on track for school, childcare, and beyond.

Making sure that your child sees their doctor for well-child visits and recommended vaccines is one of the best things you can do to protect your child and community from serious diseases that are easily spread.

Well-Child Visits and Recommended Vaccinations Are Essential

Doctor treating girl, mother holds child

Well-child visits and recommended vaccinations are essential and help make sure children stay healthy. Children who are not protected by vaccines are more likely to get diseases like measles and whooping cough . These diseases are extremely contagious and can be very serious, especially for babies and young children. In recent years, there have been outbreaks of these diseases, especially in communities with low vaccination rates.

Well-child visits are essential for many reasons , including:

Tracking growth and developmental milestones
Discussing any concerns about your child’s health
Getting scheduled vaccinations to prevent illnesses like measles and whooping cough (pertussis) and other serious diseases

sisters laughing and running with toy airplane

It’s particularly important for parents to work with their child’s doctor or nurse to make sure they get caught up on missed well-child visits and recommended vaccines.

Routinely Recommended Vaccines for Children and Adolescents

Getting children and adolescents caught up with recommended vaccinations is the best way to protect them from a variety of vaccine-preventable diseases . The schedules below outline the vaccines recommended for each age group.

See which vaccines your child needs from birth through age 6 in this easy-to-read immunization schedule.

See which vaccines your child needs from ages 7 through 18 in this easy-to-read immunization schedule.

The Vaccines for Children (VFC) program provides vaccines to eligible children at no cost. This program provides free vaccines to children who are Medicaid-eligible, uninsured, underinsured, or American Indian/Alaska Native. Check out the program’s requirements and talk to your child’s doctor or nurse to see if they are a VFC provider. You can also find a VFC provider by calling your state or local health department or seeing if your state has a VFC website.

Little girl pointing finger at adhesive bandage on her arm after being vaccinated

COVID-19 Vaccines for Children and Teens

Everyone aged 6 months and older can get an updated COVID-19 vaccine to help protect against severe illness, hospitalization and death. Learn more about making sure your child stays up to date with their COVID-19 vaccines .

Vaccines & Immunizations

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Family Life

AAP Schedule of Well-Child Care Visits

Parents know who they should go to when their child is sick. But pediatrician visits are just as important for healthy children.

The Bright Futures /American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care, known as the " periodicity schedule ." It is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence.

Schedule of well-child visits

The first week visit (3 to 5 days old)
1 month old
2 months old
4 months old
6 months old
9 months old
12 months old
15 months old
18 months old
2 years old (24 months)
2 ½ years old (30 months)
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
19 years old
20 years old
21 years old

The benefits of well-child visits

Prevention . Your child gets scheduled immunizations to prevent illness. You also can ask your pediatrician about nutrition and safety in the home and at school.

Tracking growth & development . See how much your child has grown in the time since your last visit, and talk with your doctor about your child's development. You can discuss your child's milestones, social behaviors and learning.

Raising any concerns . Make a list of topics you want to talk about with your child's pediatrician such as development, behavior, sleep, eating or getting along with other family members. Bring your top three to five questions or concerns with you to talk with your pediatrician at the start of the visit.

Team approach . Regular visits create strong, trustworthy relationships among pediatrician, parent and child. The AAP recommends well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental and social health of a child.

More information

Back to School, Back to Doctor

Recommended Immunization Schedules

Milestones Matter: 10 to Watch for by Age 5

Your Child's Checkups

Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (periodicity schedule)

Your Child’s Well Visit: What Parents Need to Know

Cute little African-American doctor on color background

In the world of pediatric care, a well visit is the equivalent of what used to be called a check-up or a physical. Once a year, parents typically make an appointment for a well visit with their family physician or pediatrician to make sure all’s well with their child and to voice any concerns. For children 3 and under, though, visits are as frequent as every few weeks in the newborn period to every 2 to 6 months. Well visits are a must for infants, toddlers, school-age children and teens alike.

Understandably, parents tend to have plenty of questions about what’s involved in a well visit : how to prepare for it, what to bring and what to expect once you get called into the doctor’s office. Let’s review all your FAQs in detail with Weill Cornell Medicine pediatrician Dr. Corey Wasserman as your guide.

What is generally included in a well visit?

Depending on your child’s age, a well visit may include immunizations, a complete physical examination, a review of your child’s medical history and a conversation regarding any concerns. The visit will typically take from 15 to 30 minutes.

“We can actually accomplish a great deal during that 15 minutes, Dr. Wasserman says. “Mainly, the idea is to check on your child’s vital signs and developmental milestones, and to listen to any concerns you may have. Most of the time, your children are indeed well, not sick, so we start out with that assumption. And if there is reason for concern, you can follow up with a separate appointment to investigate what may be happening with your child’s health.”

How should I prepare for my child’s well visit?

First, check in via Connect up to 5 days before your child’s visit to make sure we have your most up-to-date information, including your pharmacy and insurance , along with a list of your child’s medications , if any . Y ou can also review and update your responses to your health questionnaire.

When it comes to blood work and other medical r ecords, instead of uploading them to Connect , it may be preferable to email them to the Medical Records Department at [email protected] .

On the day of your appointment, please arrive 10 minutes before your scheduled time, which will allow you t o complete and submit any additional forms beforehand.

As a matter of policy, we require at least one parent or guardian to be present for the duration of the well visit. That will facilitate the best possible communication between provider and parent and allow us to secure your permission for any necessary immunizations.

If you can’t be present, you’ll need to reschedule the appointment.

What should I bring?

Please b ring :

Your insurance card and ID
School or camp forms as needed
Records of medical visits elsewhere (with a different provider or institution), if you weren’t able to submit these electronically

“ Keep in mind that your doctor may not be able to fill out school or camp forms on the day of your appointment . If they have the time to complete the form during your visit, they will do so. But it’s just as likely that the information from your child’s well visit will be entered afterwards and sent to you at a later date ,” Dr. Wasserman says.

What, exactly, will take place during the visit?

Your doctor will:

Review your child’s height, weight, and BMI (body mass index).
Check your child’s blood pressure, heart rate and breathing.
Perform a head-to-toe physical exam.
Administer any needed immunizations.
Address your concerns and offer advice regarding your child’s growth and development.

Additionally, your doctor will assess your child based on their age.

At an infant well visit, your doctor will:

Look for developmental milestones.
Measure your baby’s weight, length and head circumference.
Look at her ears, eyes, mouth and skin.
Press on his belly to detect any problems.
Inspect your baby’s genitals for tenderness, lumps or other signs of infection.

If your child is a toddler , your doctor will also:

Conduct a vision and hearing check.
Ask questions to get a sense of your child’s mental, emotional and social development.

During a school-age well check , your doctor will ask questions about the following:

Behavioral changes, if any
Physical activity
Sleeping habits
Motor, language and problem-solving skills

During a teen well visit , your doctor— optimally, someone your teenager feels comfortable with—will :

Look for indications of alcohol, tobacco or drug use, as well as anxiety or depression.
Discuss your teenager’s sexual health and provide guidance on birth control, the risk of contracting an STI (sexually transmitted infection) and other pertinent issues.

What if I need to ask the doctor about a specific medical issue?

Specific issues are considered part of a follow up or “sick” visit. These will be billed to your insurance, and you may be responsible for copayments, coinsurance or deductible payments, based on the terms of your policy.

If you’d like to address non-routine concerns during your child’s annual well visit, let your doctor ’s office know about these issues when you schedule your appointment. Depending on their complexity, your doctor may need to deal with them at a later time.

What does a follow-up or “sick” visit entail?

Any new problems or complaints
Your child’s need for new medications or tests
Referrals to a specialist
Additional treatment options for an already-existing condition

Can I combine my child’s well visit with a non-routine or sick office visit?

Combining your child’s well visit with a non-routine office visit will save you time by eliminating an extra appointment, but doing so may affect your costs. Your doctor will bill your visit based on the reason you originally gave for scheduling the appointment, plus the specific issues you raised during the appointment. Anything more than a check-up may result in unplanned out-of-pocket costs to you. For these reasons, we recommend that you schedule your child’s annual well visit and any follow-up or sick office visits separately.

The most i mportant points to remember

When scheduling your child’s well visit, clearly state the purpose of the visit.
A parent or guardian must accompany all patients under 18 to their well visit.
Arrive 10 minutes before your appointment time.
Bring all relevant information and documentation, including any forms you need filled out.
The well visit will take 15 minutes.
Review your insurance plan’s summary of benefits to clarify what will and won’t be covered during your child’s well visit.

To make an appointment with a pediatrician at Weill Cornell Medicine, go to https://weillcornell.org/services/pediatrics

Preventive care benefits for children

Coverage for children’s preventive health services.

A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

Refer to glossary for more details.

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.

The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.

Alcohol, tobacco, and drug use assessments for adolescents
Autism screening for children at 18 and 24 months
Behavioral assessments for children: Age 0 to 11 months , 1 to 4 years , 5 to 10 years , 11 to 14 years , 15 to 17 years

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Blood pressure screening for children: Age 0 to 11 months , 1 to 4 years , 5 to 10 years , 11 to 14 years , 15 to 17 years
Blood screening for newborns
Depression screening for adolescents beginning routinely at age 12
Developmental screening for children under age 3
Fluoride supplements for children without fluoride in their water source
Fluoride varnish for all infants and children as soon as teeth are present
Gonorrhea preventive medication for the eyes of all newborns
Hematocrit or hemoglobin screening for all children
Hemoglobinopathies or sickle cell screening for newborns
Hepatitis B screening for adolescents at higher risk
HIV screening for adolescents at higher risk
Hypothyroidism screening for newborns
PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Chickenpox (Varicella)
Diphtheria, tetanus, and pertussis (DTaP)
Haemophilus influenza type b
Hepatitis A
Hepatitis B
Human Papillomavirus (HPV)
Inactivated Poliovirus
Influenza (flu shot)
Meningococcal
Pneumococcal
Obesity screening and counseling
Phenylketonuria (PKU) screening for newborns
Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
Tuberculin testing for children at higher risk of tuberculosis: Age 0 to 11 months , 1 to 4 years , 5 to 10 years , 11 to 14 years , 15 to 17 years
Vision screening for all children
Well-baby and well-child visits

More information about preventive services for children

Preventive services for children age 0 to 11 months
Preventive services for children age 1 to 4 years
Preventive services for children age 5 to 10 years
Preventive services for children age 11 to 14 years
Preventive services for children age 15 to 17 years

Well-Child Care

Improving infant well-child visits.

High-quality well-child visits can improve children’s health, support caregivers’ behaviors to promote their children’s health, and prevent injury and harm. The American Academy of Pediatrics and Bright Futures recommend nine well-care visits by the time children turn 15 months of age. These visits should include a family-centered health history, physical examination, immunizations, vision and hearing screening, developmental and behavioral assessment, an oral health risk assessment, a social assessment, maternal depression screening, parenting education on a wide range of topics, and care coordination as needed. i When children receive the recommended number of high-quality visits, they are more likely to be up-to-date on immunizations, have developmental concerns recognized early, and are less likely to visit the emergency department. ii , iii , iv , v , vi , vii However, many infants do not receive the recommended number of infant well-child visits.

The Centers for Medicare & Medicaid Services (CMS) offers quality improvement (QI) technical assistance (TA) to help states increase the attendance and quality of well-child visits for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries ages 0 to 15 months.

QI TA resources , to help state Medicaid and CHIP staff and their QI partners get started improving the use of infant well-child visits for their beneficiaries

Improving Infant Well-Child Visit learning collaborative resources , to share different approaches to improving well-child visit care and state examples

For more information on these materials and other QI TA, please email [email protected] .

QI TA Resources

These resources can help states get started in developing their own infant well-child QI projects:

Getting Started on Quality Improvement Video . This video provides an overview of how Medicaid and CHIP agencies can start a QI project to improve the use of infant well-child visits. The Model for Improvement begins with small tests of change, enabling state teams to “learn their way” toward strong programs and policies.

Driver Diagram and Change Idea Table . A driver diagram is a visual display of what “drives” or contributes to improvements in infant well-child visits. This example of a driver diagram shows the relationship between the primary drivers (the high-level elements, processes, structures, or norms in the system that must change to use and quality of infant well-child visits) and the secondary drivers (the places, steps in a process, time-bound moments, or norms in which changes are made to spur improvement). The document also includes change idea tables, which contain examples of evidence-based or evidence-informed QI interventions to improve the use of infant well-child care. The change ideas were tailored for Medicaid and CHIP.

Measurement Strategy . This document provides examples of measures that can be used to monitor infant well-child care QI projects.

Improving Infant Well-Child Visits: Learning Collaborative Resources

Beginning in 2021, CMS facilitated the two year Infant Well-Child Visit learning collaborative to support state Medicaid and CHIP agencies’ efforts to improve the use of infant well-child visits from 0-15 months of age. The learning collaborative included a webinar series and an affinity group to support state Medicaid and agencies’ quality improvement efforts. The webinars, listed and linked to below, described approaches that states can use to improve attendance and quality of infant well-child visits.

California, Missouri, North Carolina, South Carolina, Texas and Virginia participated in the action-oriented affinity group where teams designed and implemented an infant well-child quality improvement (QI) project in their state with tailored TA from CMS. Learnings from participating states can be found in the state highlights brief.

Learning Collaborative Webinar Series

State Spotlights Webinar on Improving Infant-Well Child Care ( Video ) ( Transcript ). This 2024 webinar spotlighted several state QI projects from the affinity group, highlighting their strategies, partnerships, and lessons learned.

Using Payment, Policy and Partnerships to Improve Infant Well-Child Care ( Audio )( Transcript ). This August 2021 webinar focused on Medicaid and CHIP payment incentives, managed care contracts, and other strategies that can increase the use and quality of infant well-child visits and advance equity. Speakers from the CMS and Mathematica introduced CMS’ Maternal and Infant Health Initiative and shared the importance of high-quality well-child visits and the opportunities within Medicaid and CHIP to impact infant health. Speakers from Pennsylvania and Texas’ Medicaid and CHIP agencies described their efforts to expand and incentivize participation in infant well-child visits, such as through value-based purchasing, performance improvement projects, CHIP Health Services Initiatives (HSIs), and partnerships with aligned service providers like the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). State presenters offered insights into ways to incentivize efforts to close gaps in care, engage families, and improve performance on quality measures. During the Q&A session, presenters discussed the impact of the COVID-19 pandemic on well-child care, the potential of using telehealth or hybrid visits to increase access, and incentives for managed care entities, and addressing the social determinants of health in value-based payment strategies.

Improving Quality and Utilization of Infant Well-Child Visits ( Audio )( Transcript ). This September 2021 webinar focused on the characteristics of a high-performing system of well-child health care. CMS and Mathematica presenters shared the Maternal and Infant Health Initiative’s Theory of Change. Speakers from Washington and Arkansas Medicaid and CHIP agencies discussed how their states have achieved high rates of participation in infant well-child visits and how they use data to monitor performance and disparities and ensure access to services. Washington shared insights on leveraging collaborative performance improvement projects to identify and address barriers to care. Arkansas discussed the state’s per member per month incentives for performance and minimum performance measures for infant well-child visit rates. During the Q&A session, presenters highlighted efforts to improve health equity, engage parents and providers, and leverage performance measures and quality tools to improve attendance at infant well-child visits.

Models of Care that Drive Improvement in Infant Well-Child Visits ( Audio )( Transcript ). In this September 2021 webinar, three states—Oregon, Michigan, and North Carolina—shared approaches to designing and implementing models of care associated with improved infant well-child visit participation, including patient-centered medical homes (PCMHs) and home visiting. States offered insights on the importance of strategic alignment of policies, processes, and partnerships. Oregon discussed its home visiting program and quality incentive strategy for its coordinated care organizations. The state incentivizes progress on the HEDIS measures and other measures designed by the state’s Pediatric Improvement Partnership, including a measure of social-emotional health service capacity and access for infants and children. Michigan discussed how they requires MCOs to identify and publish disparities in well-child visit rates and how they encourage plans to reduce disparities. The state also uses an algorithm that automatically assigns members to MCOs based on MCOs’ performance and reimburses for maternal-infant health home visiting. North Carolina shared its Keeping Kids Well program, which aims to increase well-child visit and immunization rates and reduce disparities in those rates. The program offers coaches to practices to support their improvements, established an advisory board of key interested parties, and provides customized vaccination notices for practices to distribute to beneficiaries, in partnership with health systems and pharmaceutical companies. The state also used the Healthy Opportunities payment to incentivize the identification and redress of health-related social needs and provided the Health Equity Payment to providers serving areas with high poverty rates.

i 3 Hagan, J.F., J.S. Shaw, and P.M. Duncan (eds.). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2017.

ii Gill, J.M., A. Saldarriaga, A.G. Mainous, and D. Unger. “Does Continuity Between Prenatal and Well-Child Care Improve Childhood Immunizations?” Family Medicine, vol. 34, no. 4, April 2002, pp. 274–280.

iii Buchholz, M., and A. Talmi. “What We Talked About at the Pediatrician’s Office: Exploring Differences Between Healthy Steps and Traditional Pediatric Primary Care Visits.” Infant Mental Health Journal, vol. 33, no. 4, 2012, pp. 430–436.

iv DeVoe, J.E., M. Hoopes, C.A. Nelson, et al. “Electronic Health Record Tools to Assist with Children’s Insurance Coverage: A Mixed Methods Study.” BMC Health Services Research, vol.18, no. 1, May 2018, p. 354–360.

v Coker, T.R., S. Chacon, M.N. Elliott, et al. “A Parent Coach Model for Well-Child Care Among Low-Income Children: A Randomized Controlled Trial.” Pediatrics, vol. 137, no. 3, March 2016, p. e20153013.

vi Flores, G., H. Lin, C. Walker, M. Lee, J. Currie, R. Allgeyer, M. Fierro, M. Henry, A. Portillo, and K. Massey. “Parent Mentoring Program Increases Coverage Rates for Uninsured Latino Children.” Health Affairs, vol. 37, no. 3, 2018, pp. 403–412.

vii Hakim, R.B., and D.S. Ronsaville. “Effect of Compliance with Health Supervision Guidelines Among US Infants on Emergency Department Visits.” Archives of Pediatrics & Adolescent Medicine, vol. 156, no. 10, October 2002, pp. 1015–1020.

Doctor Visits

Make the Most of Your Child’s Visit to the Doctor (Ages 1 to 4 Years)

Health care provider talking with young girl

Take Action

Young children need to go to the doctor or nurse for a “well-child visit” 7 times between ages 1 and 4.

A well-child visit is when you take your child to the doctor to make sure they’re healthy and developing normally. This is different from other visits for sickness or injury.

At a well-child visit, the doctor or nurse can help catch any problems early, when they may be easier to treat. You’ll also have a chance to ask questions about things like your child’s behavior, eating habits, and sleeping habits.

Learn what to expect so you can make the most of each visit.

Well-Child Visits

How often do i need to take my child for well-child visits.

Young children grow quickly, so they need to visit the doctor or nurse regularly to make sure they’re healthy and developing normally.

Children ages 1 to 4 need to see the doctor or nurse when they’re:

12 months old
15 months old (1 year and 3 months)
18 months old (1 year and 6 months)
24 months old (2 years)
30 months old (2 years and 6 months)
3 years old
4 years old

If you’re worried about your child’s health, don’t wait until the next scheduled visit — call the doctor or nurse right away.

Child Development

How do i know if my child is growing and developing on schedule.

Your child’s doctor or nurse can help you understand how your child is developing and learning to do new things — like walk and talk. These are sometimes called “developmental milestones.”

Every child grows and develops differently. For example, some children will take longer to start talking than others. Learn more about child development .

At each visit, the doctor or nurse will ask you how you’re doing as a parent and what new things your child is learning to do.

Ages 12 to 18 Months

By age 12 months, most kids:.

Stand by holding on to something
Walk with help, like by holding on to the furniture
Call a parent "mama," "dada," or some other special name
Look for a toy they've seen you hide

Check out this complete list of milestones for kids age 12 months .

By age 15 months, most kids:

Follow simple directions, like "Pick up the toy"
Show you a toy they like
Try to use things they see you use, like a cup or a book
Take a few steps on their own

Check out this complete list of milestones for kids age 15 months.

By age 18 months, most kids:

Make scribbles with crayons
Look at a few pages in a book with you
Try to say 3 or more words besides “mama” or “dada”
Point to show someone what they want
Walk on their own
Try to use a spoon

Check out this complete list of milestones for kids age 18 months .

Ages 24 to 30 Months

By age 24 months (2 years), most kids:.

Notice when others are hurt or upset
Point to at least 2 body parts, like their nose, when asked
Try to use knobs or buttons on a toy
Kick a ball

Check out this complete list of milestones for kids age 24 months .

By age 30 months, most kids:

Name items in a picture book, like a cat or dog
Play simple games with other kids, like tag
Jump off the ground with both feet
Take some clothes off by themselves, like loose pants or an open jacket

Check out this complete list of milestones for kids age 30 months .

Ages 3 to 4 Years

By age 3 years, most kids:.

Calm down within 10 minutes after you leave them, like at a child care drop-off
Draw a circle after you show them how
Ask “who,” “what,” “where,” or “why” questions, like “Where is Daddy?”

Check out this complete list of milestones for kids age 3 years .

By age 4 years, most kids:

Avoid danger — for example, they don’t jump from tall heights at the playground
Pretend to be something else during play, like a teacher, superhero, or dog
Draw a person with 3 or more body parts
Catch a large ball most of the time

Check out this complete list of milestones for kids age 4 years .

Take these steps to help you and your child get the most out of well-child visits.

Gather important information.

Bring any medical records you have to the appointment, including a record of vaccines (shots) your child has received.

Make a list of any important changes in your child’s life since the last doctor’s visit, like a:

New brother or sister
Serious illness or death in the family
Separation or divorce
Change in child care

Use this tool to keep track of your child’s family health history .

Ask other caregivers about your child.

Before you visit the doctor, talk with others who care for your child, like a grandparent, daycare provider, or babysitter. They may be able to help you think of questions to ask the doctor or nurse.

What about cost?

Under the Affordable Care Act, insurance plans must cover well-child visits. Depending on your insurance plan, you may be able to get well-child visits at no cost to you. Check with your insurance company to find out more.

Your child may also qualify for free or low-cost health insurance through Medicaid or the Children’s Health Insurance Program (CHIP). Learn about coverage options for your family.

If you don’t have insurance, you may still be able to get free or low-cost well-child visits. Find a health center near you and ask about well-child visits.

To learn more, check out these resources:

Free preventive care for children covered by the Affordable Care Act
How the Affordable Care Act protects you and your family
Understanding your health insurance and how to use it [PDF - 698 KB]

Ask Questions

Make a list of questions you want to ask the doctor..

Before the well-child visit, write down 3 to 5 questions you have. This visit is a great time to ask the doctor or nurse any questions about:

A health condition your child has (like asthma or an allergy)
Changes in sleeping or eating habits
How to help kids in the family get along

Here are some questions you may want to ask:

Is my child up to date on vaccines?
How can I make sure my child is getting enough physical activity?
Is my child at a healthy weight?
How can I help my child try different foods?
What are appropriate ways to discipline my child?
How much screen time is okay for young children?

Take a notepad, smartphone, or tablet and write down the answers so you remember them later.

Ask what to do if your child gets sick.

Make sure you know how to get in touch with a doctor or nurse when the office is closed. Ask how to get hold of the doctor on call — or if there's a nurse information service you can call at night or during the weekend.

What to Expect

Know what to expect..

During each well-child visit, the doctor or nurse will ask you questions about your child, do a physical exam, and update your child's medical history. You'll also be able to ask your questions and discuss any problems you may be having.

The doctor or nurse will ask questions about your child.

The doctor or nurse may ask about:

Behavior — Does your child have trouble following directions?
Health — Does your child often complain of stomachaches or other kinds of pain?
Activities — What types of pretend play does your child like?
Eating habits — What does your child eat on a normal day?
Family — Have there been any changes in your family since your last visit?

They may also ask questions about safety, like:

Does your child always ride in a car seat in the back seat of the car?
Does anyone in your home have a gun? If so, is it unloaded and locked in a place where your child can’t get it?
Is there a swimming pool or other water around your home?
What steps have you taken to childproof your home? Do you have gates on stairs and latches on cabinets?

Your answers to questions like these will help the doctor or nurse make sure your child is healthy, safe, and developing normally.

Physical Exam

The doctor or nurse will also check your child’s body..

To check your child’s body, the doctor or nurse will:

Measure your child’s height and weight
Check your child’s blood pressure
Check your child’s vision
Check your child’s body parts (this is called a physical exam)
Give your child shots they need

Learn more about your child’s health care:

Find out how to get your child’s shots on schedule
Learn how to take care of your child’s vision

Content last updated February 2, 2024

Reviewer Information

This information on well-child visits was adapted from materials from the Centers for Disease Control and Prevention and the National Institutes of Health.

Reviewed by: Sara Kinsman, M.D., Ph.D. Director, Division of Child, Adolescent, and Family Health Maternal and Child Health Bureau Health Resources and Services Administration

Bethany Miller, M.S.W. Chief, Adolescent Health Branch Maternal and Child Health Bureau Health Resources and Services Administration

Diane Pilkey, R.N., M.P.H. Nursing Consultant, Division of Child, Adolescent, and Family Health Maternal and Child Health Bureau Health Resources and Services Administration

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Common questions about Medicare annual wellness visits

If you are a Medicare recipient, you can take advantage of annual wellness visits. These visits are a preventive health benefit available after having Medicare Part B coverage for at least one year. All Medicare Advantage Plans are required to offer annual wellness visits for their members. A nurse or nurse practitioner reviews your health status and helps you plan for health and wellness needs.

In most cases, the annual wellness visit will be followed by a separate medical visit with your primary care professional to close any health care gaps and address any problems identified during the visit.

Here are answers to common questions about annual wellness visits.

Why are annual wellness visits important.

The annual wellness visit allows you to review your health history and identify any current or potential health risks with a health care professional. The visit enables the nurse to focus on prevention and wellness while making sure you are current on recommended immunizations and health screenings like colonoscopies or mammograms. It also allows your primary care professional more time to focus on your medical concerns and needs at a separate physical exam.

Do I need to be 65 or older to have an annual wellness visit?

You do not need to be 65 or older to qualify for an annual wellness visit as long as you've been on Medicare Part B for at least one year.

How is an annual wellness visit scheduled?

If you are due for an annual wellness visit, you may be prompted to self-schedule the visit in the patient portal . You also may call your care team and ask to be scheduled.

If your visit is with a nurse or nurse practitioner, it's recommended to schedule this visit before the visit with your primary care professional. This allows your primary care professional the chance to address any concerns mentioned during your annual wellness visit.

How can I prepare for my annual wellness visit?

You may be asked to complete some questionnaires before arriving for your appointment, which will be sent to your patient portal account. If you cannot access the questionnaires before the appointment, plan to arrive at your appointment early to complete them.

It's helpful to come prepared to your visit with this information:

All medications, vitamins and supplements you take, including how much and how often you take them
Additional medical records, including immunization records
Dates of your most recent preventive services, like a colonoscopy or mammogram, if completed by another health care facility
Family health history, with as much detail as possible
List of medical providers and suppliers who provide you care, equipment or services

What can you expect during an annual wellness visit?

During the visit, you'll meet with a nurse or nurse practitioner to:.

Evaluate your fall risk
Measure your height, weight and blood pressure
Offer referrals to other health education or preventive services
Provide information related to voluntary advance care planning
Screen for cognitive impairments like dementia
Screen for depression
Update your medical and family history

What is the cost of an annual wellness visit?

Medicare offers the visit at no cost for people who have Medicare Part B coverage for at least one year before the visit. If you are referred for other tests or services, they will be billed to your insurance. If you have a separate visit with your primary care professional following your annual wellness visit, you or your insurance carrier will be responsible for the cost of that visit.

Robert Stroebel, M.D. , is a Community Internal Medicine, Geriatric and Palliative Care physician at Mayo Clinic Primary Care in Rochester and Kasson, Minnesota.

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Child and Adolescent Well-Care Visits

Well-care visits are routine examinations that provide the best opportunity for a doctor or healthcare practitioner to observe the progress of your child's physical and mental growth and development. They also offer a chance to: detect problems through screening tests; provide any necessary immunizations; allow you and your child to ask any healthcare questions you might have; and to get to know one another. Whether they are called wellness exams, or checkups, well-care visits are strongly recommended as part of preventive care.

Insured children, adolescents, and young adults ages 0 through 20 in Washington get a free health checkup every year! If you need help finding a clinic near you or have trouble scheduling a visit, call your insurance company. If you need help finding coverage, go to wahealthplanfinder.org or call 1-855-923-4633.

Family Health: The Story of Tempestt, Raul and Maui, an in-depth look, long version, English This video was co-created with Whatcom County Health & Community Services — Community Health Program.

Frequently Asked Questions

There are many benefits to completing yearly well-care visits:

The doctor/care provider can get a better picture of your child’s health and development.
You and your child get one-on-one time with your doctor or care provider to ask questions and get advice about any concerns you might have.
It’s a chance for your child to bond with their care provider and make that person a trusted presence in their life (and yours!) that you can go to when you need to.

There is evidence that regular well-care visits can help children be ready for and do better in school.

Yes! Usually, a sports physical is a check on a child’s physical health, often with a focus on risks from participating in sports. The well-care visit is meant to give your child’s doctor/healthcare provider a complete view of your child’s entire health. A full physical exam is part of the well-care visit, but also includes questions about mental, emotional, environmental, social, and behavioral health. You can talk about immunizations, any signs of risky behaviors (for example smoking or drinking alcohol), how your child has been sleeping, and other topics. The well-care visit is much more than a physical exam!

The following schedule is what is recommended by Bright Futures/the American Academy of Pediatrics (AAP) in their guidelines:

2 to 4 days for newborns discharged less than 48 hours after delivery
12 months (1 year)
24 months (2 years)
Once per year from 3 years old through 20 years old

The American Academy of Pediatrics (AAP)/Bright Futures has developed a short tip sheet for families, so you can get an idea of what to expect at a well-care visit. This tip sheet is available in both English (PDF) and Spanish (PDF) . The topics your doctor or care provider will go over are going to grow and change as your child does. For more information, you can go to the Bright Futures Tools and Resources for Families page . You can also reach out to your child’s clinic!

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Yearly "Wellness" visits

If you’ve had Medicare Part B (Medical Insurance) for longer than 12 months, you can get a yearly “Wellness” visit to develop or update your personalized plan to help prevent disease or disability, based on your current health and risk factors. The yearly “Wellness” visit isn’t a physical exam.

Your first yearly “Wellness” visit can’t take place within 12 months of your Part B enrollment or your “Welcome to Medicare” preventive visit. However, you don’t need to have had a “Welcome to Medicare” preventive visit to qualify for a yearly “Wellness” visit.

Your costs in Original Medicare

You pay nothing for this visit if your doctor or other health care provider accepts assignment .

The Part B deductible doesn’t apply.

However, you may have to pay coinsurance , and the Part B deductible may apply if your doctor or other health care provider performs additional tests or services during the same visit that Medicare doesn't cover under this preventive benefit.

If Medicare doesn't cover the additional tests or services (like a routine physical exam), you may have to pay the full amount.

Your doctor or other health care provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your doctor develop a personalized prevention plan to help you stay healthy and get the most out of your visit. Your visit may include:

Routine measurements (like height, weight, and blood pressure).
A review of your medical and family history.
A review of your current prescriptions.
Personalized health advice.
Advance care planning .

Your doctor or other health care provider will also perform a cognitive assessment to look for signs of dementia, including Alzheimer’s disease. Signs of cognitive impairment include trouble remembering, learning new things, concentrating, managing finances, and making decisions about your everyday life. If your doctor or other health care provider thinks you may have cognitive impairment, Medicare covers a separate visit to do a more thorough review of your cognitive function and check for conditions like dementia, depression, anxiety, or delirium and design a care plan.

If you have a current prescription for opioids, your doctor or other health care provider will review your potential risk factors for opioid use disorder, evaluate your severity of pain and current treatment plan, provide information on non-opioid treatment options, and may refer you to a specialist, if appropriate. Your doctor or other health care provider will also review your potential risk factors for substance use disorder, like alcohol and tobacco use , and refer you for treatment, if needed.

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What Happens During a Wellness Visit?

Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital.

Jose Luis Pelaez / Getty Images

Importance of a Wellness Visit

What to Expect
How to Prepare

A wellness visit is a health check-up that is typically conducted on an annual basis. It involves visiting your healthcare provider to check your vitals, screen for health conditions , and develop a healthcare plan for your needs.

The aim of a wellness visit is to promote health and prevent disease and disability.

This article explains why annual wellness visits are important, what you can expect during the process, and how to prepare for it.

These are some reasons why wellness visits are important.

Prevent Diseases

Most healthcare visits are categorized under diagnostic care; when you have a health problem, you visit a healthcare provider who assesses your symptoms, diagnoses your condition, and prescribes a treatment plan.

A wellness visit on the other hand is a preventative healthcare measure. The aim of preventative healthcare is to help you maintain good health and prevent health problems before they develop. The goal is to help you live a longer, healthier life.

Wellness visits assess your lifestyle, evaluate health risks, and screen for health conditions, in order to prevent health problems or catch them in the early stages. Instead of waiting to see a healthcare provider once you have a health problem, the idea is to be proactive about your health and work with your healthcare provider to prevent health problems.

People tend to think that it’s fine to skip their annual wellness visit if they’re feeling healthy. However, a 2021 study notes that wellness visits can play a role in catching chronic health conditions early, as well as helping people control for risk factors that could cause them to develop health issues down the line.

Reduce Medical Costs

Wellness visits can help prevent disease and disability, which in turn can help reduce medical costs. According to a 2016 study, a focus on preventive healthcare can significantly reduce medical costs and improve the quality of healthcare services.

What to Expect During a Wellness Visit

A wellness visit may be performed by a healthcare provider such as a doctor, nurse practitioner, clinical nurse specialist, physician assistant, or other qualified health professional.

These are some of the steps a wellness visit may involve:

Family history: Your healthcare provider may ask you detailed questions about your family’s medical history, to determine whether you are at an increased risk for certain health conditions that may be passed on genetically .
Medical history: You may also be asked questions about your personal medical history. It can include information about any current or previous diseases, allergies, illnesses, surgeries, accidents, medications, vaccinations, and hospitalizations, as well as the results of any medical tests and examinations.
Measurements: Your healthcare provider may measure your height, weight, heart rate, blood pressure, and other vital signs. Doing this regularly can help you establish a baseline as well as track any changes in your health.
Cognitive assessment: Your healthcare provider may assess your ability to think, remember, learn, and concentrate, in order to screen for conditions such as Alzhemer’s disease and dementia.
Mental health assessment: Your healthcare provider may also assess your mental health and state of mind, to help screen for conditions such as depression and other mood disorders.
Physical assessment: Your healthcare provider may perform a physical examination to check your reflexes. They may also perform a neurological exam, a head and neck exam, an abdominal exam, or a lung exam.
Functional assessment: Your healthcare provider may assess your hearing, your vision, your ability to perform day-to-day tasks, your risk of falling, and the safety of your home environment.
Lifestyle factors: Your healthcare provider may ask you questions about your nutrition, fitness, daily habits, work, stress levels, and consumption of substances such as tobacco, nicotine, alcohol, and drugs.
Health risk assessment: Based on this information, your healthcare provider will evaluate your health, and determine whether you are at an increased risk for any health conditions.
Health advice: Your healthcare provider may advise you on steps you can take to improve your health, control risk factors, and prevent disease and disability. This may include nutrition counseling, an exercise plan, flu shot and vaccination recommendations, and fall prevention strategies, among other things.
Screenings: Your healthcare provider may recommend that you get screened for certain health conditions such as depression , cholesterol, blood pressure, diabetes, cancer, heart disease, or liver conditions. This may involve blood work, imaging scans, or other screening tests.
Medication review: Your healthcare provider may review your medication and adjust it, if required. This can include prescription medication, over-the-counter medication, vitamins, supplements, and herbal or traditional medication.
Referrals and resources: If required, your healthcare provider will provide a referral to other healthcare specialists. They can also provide other resources that may be helpful, such as counseling services or support groups , for instance.
Medical providers: Your healthcare provider will work with you to create or update a list of your current medical providers and equipment suppliers. This list can be helpful in case of an emergency.
Healthcare plan: Your healthcare provider will work with you to create a healthcare plan that is tailored to your needs. The plan will serve as a checklist that will list any screenings or preventive measures you need to take over the next five to 10 years.

The screenings, assessments, and healthcare plan can vary depending on factors such as your age, gender, lifestyle, and risk factors.

How to Prepare for a Wellness Visit

These are some steps that can help you prepare for a wellness visit:

Fill out any required questionnaires: Your healthcare provider may ask you to fill out a questionnaire before your visit. The questionnaire may include some of the factors listed above. Make sure you do it before your visit, so that you can make the most of your time with your healthcare provider.
Carry your medications: If possible, try to carry your medications with you to show them to your healthcare provider.
Take your medical documents along: It can be helpful to carry your prescriptions, immunization records, as well as the results of any medical tests or screenings you have had, to help give your healthcare provider a more accurate picture of your health status.
Ask someone to go with you: You may want to take a trusted friend or family member along with you for the wellness visit. They can assist you if required, take notes for you, ask questions, and help you remember your healthcare provider’s instructions.
Note down questions and concerns: A wellness visit is a good opportunity to ask your healthcare provider any questions you have about your health and tell them about any health problems or concerns you have. Making a list and carrying it with you to the visit can help ensure that you don’t miss anything.
Check your insurance plan: Most insurance plans cover wellness visits; however, what is covered as part of the wellness visit can vary depending on the plan. It can be helpful to know what preventative services and wellness visits your plan offers. It’s important to check that your healthcare provider takes your insurance and to inform them that you’ll be coming for a wellness visit when you schedule your appointment.

A Word From Verywell

A wellness visit can help you evaluate your health status, understand your risk for specific health conditions, and give you the information and resources you need to improve your health.

After you go for a wellness visit, it’s important that you start implementing your healthcare provider’s advice, take any follow-up appointments necessary, and take steps to improve your health.

U.S. Department of Health and Human Services. Get your wellness visit every year .

University Hospitals. What you need to know about wellness visits .

Liss DT, Uchida T, Wilkes CL, Radakrishnan A, Linder JA. General health checks in adult primary care: a review . JAMA . 2021;325(22):2294-2306. doi:10.1001/jama.2021.6524

Musich S, Wang S, Hawkins K, Klemes A. The impact of personalized preventive care on health care quality, utilization, and expenditures . Popul Health Manag . 2016;19(6):389-397. doi:10.1089/pop.2015.0171

Alzheimer’s Association. Annual wellness visit .

University of Michigan Health. Your yearly wellness visit .

By Sanjana Gupta Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

Medicare Wellness Visits Back to MLN Print November 2023 Updates

What’s Changed?

Added information about monthly chronic pain management and treatment services
Added information about checking for cognitive impairment during annual wellness visits
Added information about Social Determinants of Health Risk Assessments as an optional element of annual wellness visits

Quick Start

The Annual Wellness Visits video helps you understand these exams, as well as their purpose and claim submission requirements.

Medicare Physical Exam Coverage

Initial Preventive Physical Exam (IPPE)

Review of medical and social health history and preventive services education.

✔ New Medicare patients within 12 months of starting Part B coverage

✔ Patients pay nothing (if provider accepts assignment)

Annual Wellness Visit (AWV)

Visit to develop or update a personalized prevention plan and perform a health risk assessment.

✔ Covered once every 12 months

Routine Physical Exam

Exam performed without relationship to treatment or diagnosis of a specific illness, symptom, complaint, or injury.

✘ Medicare doesn’t cover a routine physical

✘ Patients pay 100% out-of-pocket

Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health :

Health Equity Technical Assistance Program
Disparities Impact Statement

Communication Avoids Confusion

As a health care provider, you may recommend that patients get services more often than we cover or that we don’t cover. If this happens, help patients understand they may have to pay some or all costs. Communication is key to ensuring patients understand why you’re recommending certain services and whether we cover them.

Initial Preventive Physical Exam

The initial preventive physical exam (IPPE), also known as the “Welcome to Medicare” preventive visit, promotes good health through disease prevention and detection. We pay for 1 IPPE per lifetime if it’s provided within the first 12 months after the patient’s Part B coverage starts.

1. Review the patient’s medical and social history

At a minimum, collect this information:

Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments)
Current medications, supplements, and other substances the person may be using
Family history (review the patient’s family and medical events, including hereditary conditions that place them at increased risk)
Physical activities
Social activities and engagement
Alcohol, tobacco, and illegal drug use history

Learn information about Medicare’s substance use disorder (SUD) services coverage .

2. Review the patient’s potential depression risk factors

Depression risk factors include:

Current or past experiences with depression
Other mood disorders

Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. APA’s Depression Assessment Instruments has more information.

3. Review the patient’s functional ability and safety level

Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the patient’s:

Ability to perform activities of daily living (ADLs)
Hearing impairment
Home and community safety, including driving when appropriate

Medicare offers cognitive assessment and care plan services for patients who show signs of impairment.

Height, weight, body mass index (BMI) (or waist circumference, if appropriate), blood pressure, balance, and gait
Visual acuity screen
Other factors deemed appropriate based on medical and social history and current clinical standards

5. End-of-life planning, upon patient agreement

End-of-life planning is verbal or written information you (their physician or practitioner) can offer the patient about:

Their ability to prepare an advance directive in case an injury or illness prevents them from making their own health care decisions
If you agree to follow their advance directive
This includes psychiatric advance directives

6. Review current opioid prescriptions

For a patient with a current opioid prescription:

Review any potential opioid use disorder (OUD) risk factors
Evaluate their pain severity and current treatment plan
Provide information about non-opiod treatment options
Refer to a specialist, as appropriate

The HHS Pain Management Best Practices Inter-Agency Task Force Report has more information. Medicare now covers monthly chronic pain management and treatment services .

7. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them to treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

8. Educate, counsel, and refer based on previous components

Based on the results of the review and evaluation services from the previous components, provide the patient with appropriate education, counseling, and referrals.

9. Educate, counsel, and refer for other preventive services

Include a brief written plan, like a checklist, for the patient to get:

A once-in-a-lifetime screening electrocardiogram (ECG), as appropriate
Appropriate screenings and other covered preventive services

Use these HCPCS codes to file IPPE and ECG screening claims:

Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment

Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv

* Section 60.2 of the Medicare Claims Processing Manual, Chapter 9 has more information on how to bill HCPCS code G0468.

Report a diagnosis code when submitting IPPE claims. We don’t require you to use a specific IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an IPPE when performed by a:

Physician (doctor of medicine or osteopathy)
Qualified non-physician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist)

When you provide an IPPE and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

IPPE Resources

42 CFR 410.16
Section 30.6.1.1 of the Medicare Claims Processing Manual, Chapter 12
Section 80 of the Medicare Claims Processing Manual, Chapter 18
U.S. Preventive Services Task Force Recommendations

No. The IPPE isn’t a routine physical that some patients may get periodically from their physician or other qualified non-physician practitioner (NPP). The IPPE is an introduction to Medicare and covered benefits, and it focuses on health promotion, disease prevention, and detection to help patients stay well. We encourage providers to inform patients about the AWV during their IPPE. The Social Security Act explicitly prohibits Medicare coverage of routine physical exams.

No. The IPPE and AWV don’t include clinical lab tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.

No. We waive the coinsurance, copayment, and Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening electrocardiogram (ECG) (HCPCS codes G0403, G0404, or G0405).

A patient who hasn’t had an IPPE and whose Part B enrollment began in 2023 can get an IPPE in 2024 if it’s within 12 months of the patient’s Part B enrollment effective date.

We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, find your MAC’s website .

Annual Wellness Visit Health Risk Assessment

The annual wellness visit (AWV) includes a health risk assessment (HRA). View the HRA minimum elements summary below. A Framework for Patient-Centered Health Risk Assessments has more information, including a sample HRA.

Perform an HRA

You or the patient can update the HRA before or during the AWV
Consider the best way to communicate with underserved populations, people who speak different languages, people with varying health literacy, and people with disabilities
Demographic data
Health status self-assessment
Psychosocial risks, including, but not limited to, depression, life satisfaction, stress, anger, loneliness or social isolation, pain, suicidality, and fatigue
Behavioral risks, including, but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (for example, seat belt use), and home safety
Activities of daily living (ADLs), including dressing, feeding, toileting, and grooming; physical ambulation, including balance or fall risks and bathing; and instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, transportation, shopping, managing medications, and handling finances

1. Establish the patient’s medical and family history

At a minimum, document:

Medical events of the patient’s parents, siblings, and children, including hereditary conditions that place them at increased risk
Use of, or exposure to, medications, supplements, and other substances the person may be using

2. Establish a current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.

Height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure
Other routine measurements deemed appropriate based on medical and family history

4. Detect any cognitive impairments the patient may have

Check for cognitive impairment as part of the first AWV.

Assess cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others. Consider using brief cognitive tests, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Alzheimer’s and Related Dementia Resources for Professionals has more information.

5. Review the patient’s potential depression risk factors

6. Review the patient’s functional ability and level of safety

Ability to perform ADLs

7. Establish an appropriate patient written screening schedule

Base the written screening schedule on the:

Checklist for the next 5–10 years
United States Preventive Services Task Force and Advisory Committee on Immunization Practices (ACIP) recommendations
Patient’s HRA, health status and screening history, and age-appropriate preventive services we cover

8. Establish the patient’s list of risk factors and conditions

A recommendation for primary, secondary, or tertiary interventions or report whether they’re underway
Mental health conditions, including depression, substance use disorders , suicidality, and cognitive impairments
IPPE risk factors or identified conditions
Treatment options and associated risks and benefits

9. Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs

Include referrals to educational and counseling services or programs aimed at:

Fall prevention
Physical activity
Tobacco-use cessation
Social engagement
Weight loss

10. Provide advance care planning (ACP) services at the patient’s discretion

ACP is a discussion between you and the patient about:

Preparing an advance directive in case an injury or illness prevents them from making their own health care decisions
Future care decisions they might need or want to make
How they can let others know about their care preferences
Caregiver identification
Advance directive elements, which may involve completing standard forms

Advance directive is a general term that refers to various documents, like a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. The Advance Care Planning fact sheet has more information.

We don’t limit how many times the patient can revisit the ACP during the year, but cost sharing applies outside the AWV.

11. Review current opioid prescriptions

Review any potential OUD risk factors
Provide information about non-opioid treatment options

12. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them for treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

13. Social Determinants of Health (SDOH) Risk Assessment

Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and ensure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate.

1. Review and update the HRA

2. Update the patient’s medical and family history

At a minimum, document updates to:

3. Update current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including those added because of the first AWV personalized prevention plan services (PPPS), and any behavioral health providers.

Weight (or waist circumference, if appropriate) and blood pressure

5. Detect any cognitive impairments patients may have

Check for cognitive impairment as part of the subsequent AWV.

6. Update the patient’s written screening schedule

Base written screening schedule on the:

7. Update the patient’s list of risk factors and conditions

Mental health conditions, including depression, substance use disorders , and cognitive impairments
Risk factors or identified conditions

8. As necessary, provide and update patient PPPS, including personalized health advice and appropriate referrals to health education or preventive counseling services or programs

9. Provide advance care planning (ACP) services at the patient’s discretion

10. Review current opioid prescriptions

11. Screen for potential substance use disorders (SUDs)

12. Social Determinants of Health (SDOH) Risk Assessment

Preparing Eligible Patients for their AWV

Help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment:

Medical records, including immunization records
Detailed family health history
Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists

Use these HCPCS codes to file AWV claims:

Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

Report a diagnosis code when submitting AWV claims. We don’t require you to use a specific AWV diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an AWV if performed by a:

Medical professional (including health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of medical professionals directly supervised by a physician

When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV, and G0439 is for subsequent AWVs. Don’t bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. We deny these claims with messages indicating the patient reached the benefit maximum for the time period.

Medicare telehealth includes HCPCS codes G0438 and G0439.

ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a patient to discuss their health care wishes and medical treatment preferences if they become unable to communicate or make decisions about their care. At the patient’s discretion, you can provide the ACP during the AWV.

Use these CPT codes to file ACP claims as an optional AWV element:

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Report a diagnosis code when submitting an ACP claim as an optional AWV element. We don’t require you to use a specific ACP diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

We waive both the Part B ACP coinsurance and deductible when it’s:

Provided on the same day as the covered AWV
Provided by the same provider as the covered AWV
Billed with modifier 33 (Preventive Service)
Billed on the same claim as the AWV

We waive the ACP deductible and coinsurance once per year when billed with the AWV. If we deny the AWV billed with ACP for exceeding the once-per-year limit, we’ll apply the ACP deductible and coinsurance .

We apply the deductible and coinsurance when you deliver the ACP outside the covered AWV. There are no limits on the number of times you can report ACP for a certain patient in a certain period. When billing this service multiple times, document changes in the patient’s health status or wishes about their end-of-life care.

SDOH is important in assessing patient histories; in assessing patient risk; and in guiding medical decision making, prevention, diagnosis, care, and treatment. In the CY 2024 Medicare Physician Fee Schedule final rule , we added a new SDOH Risk Assessment as an optional, additional element of the AWV. At both yours and the patient’s discretion, you may conduct the SDOH Risk Assessment during the AWV.

Use this HCPCS code to file SDOH Risk Assessment claims as an optional AWV element:

Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes

Report a diagnosis code when submitting an SDOH Risk Assessment claim as an optional AWV element. We don’t require you to use a specific SDOH Risk Assessment diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

The implementation date for SDOH Risk Assessment claims is July 1, 2024. We waive both the Part B SDOH Risk Assessment coinsurance and deductible when it’s:

We waive the SDOH Risk Assessment deductible and coinsurance once per year when billed with the AWV.

If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when you deliver the SDOH Risk Assessment outside the covered AWV.

AWV Resources

42 CFR 410.15
Section 140 of the Medicare Claims Processing Manual, Chapter 18

No. The AWV isn’t a routine physical some patients may get periodically from their physician or other qualified NPP. We don’t cover routine physical exams.

No. We waive the coinsurance, copayment, and Part B deductible for the AWV.

We cover an AWV for all patients who’ve had Medicare coverage for longer than 12 months after their first Part B eligibility date and who didn’t have an IPPE or AWV within those past 12 months. We cover only 1 IPPE per patient per lifetime and 1 additional AWV every 12 months after the date of the patient’s last AWV (or IPPE). Check eligibility to find when a patient is eligible for their next preventive service.

Generally, you may provide other medically necessary services on the same date as an AWV. The deductible and coinsurance or copayment applies for these other medically necessary and reasonable services.

You have different options for accessing AWV eligibility information depending on where you practice. Check eligibility to find when a patient is eligible for their next preventive service. Find your MAC’s website if you have specific patient eligibility questions.

Know the Differences

An IPPE is a review of a patient’s medical and social health history and includes education about other preventive services .

We cover 1 IPPE per lifetime for patients within the first 12 months after their Part B benefits eligibility date
We pay IPPE costs if the provider accepts assignment

An AWV is a review of a patient’s personalized prevention plan of services and includes a health risk assessment.

We cover an annual AWV for patients who aren’t within the first 12 months after their Part B benefits eligibility date
We cover an annual AWV 12 months after the last AWV’s (or IPPE’s) date of service
We pay AWV costs if the provider accepts assignment

A routine physical is an exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.

We don’t cover routine physical exams, but the IPPE, AWV, or other Medicare benefits cover some routine physical elements
Patients pay 100% out of pocket

View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure .

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

A systematic approach will help prevent these visits from overwhelming your practice.

CYNTHIA HUGHES, CPC

Fam Pract Manag. 2011;18(4):10-14

Cindy Hughes is the AAFP's coding and compliance specialist and a contributing editor to Family Practice Management . Author disclosure: no relevant financial affiliations disclosed.

This is a corrected version of the article that appeared in print.

In two previous articles, I explained the elements required for the new Medicare annual wellness visit (AWV). 1 , 2 In this article, I share ideas and emerging best practices for providing the components of the AWV in a way that most benefits your patients while protecting your practice from loss of income and productivity. From educating patients about what to expect at a wellness visit to planning the delivery of the related services, there are opportunities to make the most of the AWV for patients and your practice.

Manage patient expectations

Although the AWV has been referred to as a “physical” in ads encouraging Medicare beneficiaries to take advantage of this new benefit, a head-to-toe exam is not required. Patients may also expect to receive diagnosis and management of problems at this encounter without charge. To set the right expectations and give patients fair warning of additional expenses they may incur, a simple one-page letter may be effective.

SAMPLE LETTER: A WORD TO OUR PATIENTS ABOUT MEDICARE AND WELLNESS CARE

Dear Patient,

We want you to receive wellness care – health care that may lower your risk of illness or injury. Medicare pays for some wellness care, but it does not pay for all the wellness care you might need. We want you to know about your Medicare benefits and how we can help you get the most from them.

The term “physical” is often used to describe wellness care. But Medicare does not pay for a traditional, head-to-toe physical. Medicare does pay for a wellness visit once a year to identify health risks and help you to reduce them. At your wellness visit, our health care team will take a complete health history and provide several other services:

Screenings to detect depression, risk for falling and other problems,

A limited physical exam to check your blood pressure, weight, vision and other things depending on your age, gender and level of activity,

Recommendations for other wellness services and healthy lifestyle changes.

Before your appointment, our staff will ask you some questions about your health and may ask you to fill out a form.

A wellness visit does not deal with new or existing health problems. That would be a separate service and requires a longer appointment. Please let our scheduling staff know if you need the doctor's help with a health problem, a medication refill or something else. We may need to schedule a separate appointment. A separate charge applies to these services, whether provided on the same date or a different date than the wellness visit .

We hope to help you get the most from your Medicare wellness benefits. Please contact us with any questions.

Develop scheduling protocols

Since the AWV has a lot of components, it may take generous amounts of both staff and physician resources to provide the service. Taking some time to determine how these appointments best fit into your existing schedule and to create a scheduling protocol should save more time and frustration later. For example, do you want to schedule these appointments on certain days of the week, in the morning with patients fasting in anticipation of lab testing, or after specified tests have been ordered and results charted? You should also consider whether you will schedule both an AWV and a problem-oriented evaluation and management service for the same appointment and advise staff on how to address this issue with patients.

Do pre-visit planning

Your staff will need to verify up front not only the patient's Medicare Part B effective date but also whether the patient has received an AWV from any physician in the last 11 months. Otherwise, your service may be denied, leaving the patient with an unexpected bill.

The same verification will be needed for other preventive services that you might advise patients to receive in conjunction with the AWV. It may be ideal to have staff note the last date of these preventive services on an AWV documentation form in advance of the visit. This information can be obtained in several ways. A chart review or phone interview could be conducted soon after the visit is scheduled to gather a pre-visit history. More reliably for purposes of payment, staff could use an electronic insurance inquiry or Internet eligibility service to verify eligibility for preventive services. Whatever the approach, having this information before the visit will help you to determine which preventive services are needed and whether the patient is eligible to have these paid for by Medicare.

A pre-visit history can also identify whether the patient needs tests such as the cardiovascular and diabetes screening blood tests, which should be completed prior to the AWV to allow discussion of the results at the encounter. Additional considerations might include whether the patient should be instructed to not eat before the visit and whether occult blood test cards should be provided before the visit with instructions for the patient to return the cards at his or her appointment (since compliance with this test is low, you might ask that the patient bring the cards to the visit, whether completed or not).

Define the encounter

It is important to work through the required elements of the AWV, define each step, determine which staff will perform each step and identify any tools or resources needed. The annual wellness visit encounter form published in the January/February 2011 issue of FPM is a useful reference for this purpose.

History . To begin with, you'll have an extensive patient history and medication list to complete. Do you want to send a form to the patient for completion prior to the visit, conduct phone interviews prior to the visit, or have ancillary staff gather this information when the patient arrives for the appointment? However you approach it, this information can be documented and ready for you to review with the patient when you enter the exam room.

Screening for depression, functional ability and safety . Depending on the scope of practice and skill levels of your staff, the depression screening and the functional ability and safety screening may also be conducted by ancillary staff in advance of your visit with the patient.

Cognitive assessment . The assessment that the Centers for Medicare & Medicaid Services (CMS) envisioned when establishing the AWV requirements will be based on your interactions with the patient and input from family members or other caregivers present during the encounter. Gathering impressions from the staff who obtained the patient history or performed other elements of the encounter may also be beneficial. Documentation should include evidence of assessment, such as notations of the patient's general appearance, affect, speech, memory and motor skills. You may also wish to use an instrument such as the Mini-Cog, the Montreal Cognitive Assessment or the Mini-Mental State Exam.

Screening for hearing and vision loss . This component may be met by questioning the patient or caregiver about the patient's hearing. You may wish to conduct the whisper test. A visual acuity test should also be performed.

The remainder of the physical exam . Medicare regulations do not set forth requirements for other aspects of the physical exam. These are for you to determine based on the patient's age, gender, level of physical activity, last exam and known medical conditions. One decision you will have to make is whether to perform the clinical breast and pelvic exam at the same encounter as the AWV. They are separately defined Medicare benefits, but at least one Medicare contractor has said that, if both services are provided at the same encounter, the fee for performing the breast and pelvic exam should be carved out of the fee for the AWV (equivalent to not charging for the breast and pelvic exam but reporting it). You may wish to clarify this with your Medicare contractor up front.

Plan for efficient follow-up care

Patient risks and problems identified through the history, screening and exam must be addressed by continuing interventions already in place, ordering further screening or recommending new interventions. Your documentation should reflect your discussions of the risks and benefits of each of these. Referrals to other providers and community services should be documented as appropriate. A preventive service plan for the next five to 10 years should be developed, and a screening plan or checklist should be provided to the patient following the visit. Discussing advance directives or surrogate decision makers may also be appropriate but is not required.

You and your staff can save significant time by establishing protocols for responding to positive screening results and identifying resources you'll use for follow-up. You'll want to consider questions like these:

If a patient gives a positive response to both questions in the simple depression screening, will you be prepared to conduct further screening such as PHQ-9? If depression is diagnosed, how will you address it?

If a patient has been recently injured in a fall or has other indications of impaired functional ability or safety hazards in his or her home, how will these be addressed?

Can you implement standing orders for influenza and pneumococcal vaccinations?

Will your practice provide brief behavioral health, medical nutritional and perhaps even minimal physical therapy services as part of the AWV? If you don't offer these services, are you prepared to make referrals? Note that although Medicare contractors still pay separately for these services, it is likely that these codes will soon be bundled with codes for the AWV. If your practice includes licensed professionals who provide these services, you may wish to bring the patient back on a different date to continue this care.

What patient handouts may be most helpful, and where will you find them?

What community services would benefit your patients (for example, meals and transportation services for the elderly), and can you share this information easily?

You likely have many of these resources already, and the resource list below includes links to additional screening tests, tools and information that can facilitate AWV care. If staff are trained in your practice protocols and can easily access information at the encounter, care management and coordination will be easier. See “ The annual wellness visit: Putting it all together ” for a vignette that describes an efficient annual wellness visit.

THE ANNUAL WELLNESS VISIT: PUTTING IT ALL TOGETHER

Jim Smith calls his doctor's office to ask about the free Medicare physical he's heard about. Sally at the scheduling desk explains that an annual wellness visit (AWV) is paid in full by Medicare but that there may be other charges if the doctor addresses problems or orders certain testing. She checks the effective date of Part B coverage on the file copy of Mr. Smith's Medicare card noting that he is eligible for the AWV. Mr. Smith accepts an appointment with Dr. Williams for a time designated for preventive visits. Sally mails Mr. Smith information on what to expect and what to bring to the visit and history forms for him to complete and return.

Ann in the billing office verifies Mr. Smith's eligibility using the Medicare contractor's online system. She confirms the effective date, deductible remaining and next eligibility dates for covered preventive services. She forwards these details to Kelly, the LPN who will develop a pre-visit plan.

Before Mr. Smith's visit, Kelly calls him to verify his appointment, discuss his expectations and provide information. Kelly explains that the Medicare eligibility records indicate he has not received a pneumococcal vaccination but did receive an influenza vaccination several months ago. She also asks whether he has received the herpes zoster vaccine covered under Medicare Part D. Kelly explains Dr. Williams' recommendation and the importance of these vaccines. Mr. Smith agrees, so Kelly plans for doses to be available at the visit pending verification of the herpes zoster vaccination coverage. Kelly asks if he wishes to address specific medical concerns at this visit. He asks if he can get refills on the GERD medication prescribed two months ago, noting it has had good results. Kelly makes a note to ask Dr. Williams.

Kelly meets briefly with Dr. Williams on the morning of Dr. Smith's visit to review the day's visits. Dr. Williams confirms that the vaccines should be given and approves the refill.

When Mr. Smith arrives for his appointment, Sally greets him and asks for the completed history forms, which she scans into the electronic health record (EHR) system.

Kelly escorts Mr. Smith to an exam room where she reviews his history, adding this and further information to the EHR's AWV template. She also reviews each medication with Mr. Smith, noting whether he is taking each as prescribed.

She then inquires about falls in the past year, noting none but discussing safety features. Mr. Smith notes that a home health agency that cared for his wife provided a safety checklist last year and he did install rails in the bathroom.

Next Kelly obtains and notes measurements including blood pressure, height, weight, BMI, pulse and respiration. She proceeds with a simple two-question depression screening, which is negative. She conducts a simple gait assessment in the hall and documents the results. She also asks Mr. Smith to read an eye chart posted in the hall and documents this as well. She asks about his last eye appointment. He has not had one for several years because new glasses seemed unaffordable. Kelly offers a patient handout that lists vision center discounts for AARP and AAA members.

Kelly confirms that Mr. Smith still wishes to receive vaccinations. She reviews the vaccine information sheets with Mr. Smith and informs him about his Part D plan's coverage of the herpes zoster vaccine. She then administers the vaccines and records them in the EHR.

Dr. Williams reviews Kelly's notes and Mr. Smith's lists of medications and other health care providers. He asks Mr. Smith's reason for taking a garlic supplement and then discusses the pros and cons with him. Dr. Williams explains the need for vision care to detect changes or early signs of disease, and Mr. Smith agrees to make an appointment soon. Dr. Williams notes a negative response to questions about hearing difficulty and steps behind the patient to whisper, “Can you hear me now?” Mr. Smith clearly hears and chuckles. No one accompanied Mr. Smith to this visit, so Dr. Williams does not get family input but sees no evidence of cognitive deficit; Mr. Smith has normal appearance, evidence of good hygiene and ably counts backwards from 100 by 7s.

Because Mr. Smith was seen just two months earlier and reports no new problems, Dr. Williams only examines his eyes, ears, nose and throat and listens to his heart and lungs.

Having completed the history, screenings and exam, Dr. Williams turns to discussions of health risks, current interventions and recommendations. Mr. Smith's BMI indicates that exercise and dietary changes are recommended. They discuss these, and Dr. Williams provides a patient handout on strengthening and balance exercises that they discuss.

Dr. Williams reminds him to get a flu shot in the fall and notes this on the recommendations list that Mr. Smith will take with him. Kelly previously noted the dates of Mr. Smith's last PSA test, colonoscopy and cholesterol check. Dr. Williams recommends repeating these at intervals that he specifies in his notes. He orders a fasting glucose test to screen for diabetes since Mr. Smith qualifies for this Medicare benefit based on his weight and hypertension.

Mr. Smith indicates understanding of the prevention plan and other materials provided during the visit, so Dr. Williams thanks him for coming in and then asks Kelly to schedule Mr. Smith's fasting glucose test. Kelly schedules the test and assures Mr. Smith that the doctor ordered his prescription refill. He wants to schedule an ophthalmology visit on his own, so she provides information. She shows him to the check-out desk, where he is told there is no charge for today's visit and is reminded to fast prior to his upcoming diabetes screening test.

The final step in providing the AWV is to get paid for all you do. Be sure your documentation is complete and signed. Establish processes to capture ancillary services such as lab testing or vaccines administered. Many have asked what ICD-9 code should be reported, but Medicare has not specified a code. Codes in the V70 series should suffice for the primary diagnosis, with additional codes for problems identified and addressed or any preventive services delivered.

These tips should ease the delivery of the AWV. If you have tips of your own, please share them with FPM . With some preparation and teamwork, this service can be one that is beneficial to both patients and physicians.

Articles on preventive care for older patients

Answers to Your Questions About Medicare AnnualWellness Visits (FPM)

What You Need to Know About the Medicare PreventiveServices Expansion (FPM). Features an annual wellness visit encounter form

The Geriatric Assessment (AFP)

Weight loss and exercise

Americans in Motion – Healthy Interventions (AIM-HI)

First Step to Active Health for Providers

New Health Partnerships self-management resources

Cognitive assessment

Mental Status Examination in Primary Care: A Review (AFP)

Soapnote online calculators (with printable results)http://www.soapnote.org/mental-health/folstein-mini-mental-status-exam/ and http://www.soapnote.org/elder-care/mini-cog-screen-for-dementia/

Montreal Cognitive Assessment

Society for Hospital Medicine mini-cog form

Depression screening and treatment

Depression: What You Should Know (AFP patient handout)

PHQ-9 depression screening tool

U.S. Preventive Services Task Force recommendation

Patient safety

Ambulatory Devices for Chronic Gait Disorders (AFP)

Gait and Balance Disorders in Older Adults (AFP)

Prevention of Falls in Older Patients (AFP)

Vision Loss in Older Persons (AFP)

AARP home safety checklist

Assessing and Counseling Older Drivers (AMA)

Tobacco cessation

AAFP Ask and Act Practice Toolkit

Preventive service recommendations

AHRQ Preventive Service Selector

2011 recommended adult immunization schedule

Referrals to other providers and resources

American Dietetic Association – Registered Dietitian Finder

American Physical Therapy Association – Find a PT

Eldercare Locator

Full Circle of Care

National Council on Aging

Hughes C. What you need to know about the Medicare preventive services expansion. Fam Pract Manag . January/February 2011:22–25. https://www.aafp.org/fpm/2011/0100/p22.html .

Hughes C. Answers to your questions about Medicare annual wellness visits. Fam Pract Manag . March/April 2011:13–15. https://www.aafp.org/fpm/2011/0300/p13.html .

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The benefits of well-child visits

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v.15(9); 2023 Sep
PMC10576162

Analyzing Best Practices for Pediatric Well-Child Clinic Visits in the United States for Children Aged Three to Five Years: A Review

Okelue e okobi.

1 Family Medicine, Larkin Community Hospital Palm Springs Campus, Miami, USA

2 Family Medicine, Medficient Health Systems, Laurel, USA

3 Family Medicine, Lakeside Medical Center, Belle Glade, USA

Patience F Akahara

4 Family Medicine, Inglewood Medical Centre, Edmonton, CAN

Onyinyechukwu B Nwachukwu

5 Neurosciences and Psychology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA

6 Family Medicine, American International School of Medicine Georgetown, Guyana, USA

Thelma O Egbuchua

7 Pediatrics and Neonatology, Delta State University Teaching Hospital, Oghara, NGA

Olamide O Ajayi

8 Internal Medicine, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University, Sagamu, NGA

Kelechukwu P Oranu

9 Obstetrics and Gynecology, Kenechukwu Specialist Hospital and Maternity Enugu, Enugu, NGA

Ifreke U Ibanga

10 Pediatrics, Thompson General Hospital, Manitoba, CAN

Inadequate routine healthcare check-up visits for children aged three to five years impose substantial economic and social burdens due to morbidity and mortality. The absence of regular well-child visits and vaccinations leads to avoidable diseases, underscoring the need for a renewed emphasis on childhood immunizations and check-ups. Out of 160 articles initially screened after removing duplicates, 45 were chosen for full-text review following initial title and abstract screening by two independent reviewers. Afterward, 20 studies met the predefined inclusion criteria during the final assessment of full-text articles, and data were systematically extracted from these selected studies using standardized forms to ensure accuracy and consistency. Well-child visits promote holistic development, health, and well-being in children aged three to five years. Following established guidelines and evidence-based practices, healthcare professionals provide assessments, vaccinations, and guidance for a healthy future. Despite challenges, well-child visits are vital for preventive care, empowering informed decisions for children's growth and development. The benefits of well-child visits encompass growth monitoring, anticipatory guidance, and preventive measures, crucial for children with chronic illnesses. Key components include comprehensive assessments, developmental screenings, vision and hearing evaluations, immunizations, health education, and counseling. In the case of juvenile diabetes, parental education is paramount. Parents need to understand the intricacies of insulin administration, including proper dosage calculation based on glucose measurements, meal planning, and the importance of timing insulin injections. Implementing guidelines and principles by organizations such as Bright Futures and the American Academy of Pediatrics ensures holistic care, parent involvement, and evidence-based practices. This review explores best practices and guidelines for such visits, emphasizing their role in monitoring and promoting children's development.

Introduction and background

Pediatric-associated morbidity and mortality resulting from inadequate routine healthcare check-up visits impose a considerable national economic and social burden worldwide, including in the United States. The data collected from medical check-up records from January 2019 to December 2020 revealed that the risk of disease-related adverse outcomes in a population is higher if routine non-healthcare check-up visits are ignored [ 1 - 4 ]. For example, missed vaccinations have been identified as a significant contributor to the rise of pediatric vaccine-preventable illnesses in the United States. According to the Centers for Disease Control and Prevention (CDC), millions of children in the United States are under-vaccinated or unvaccinated against preventable diseases [ 1 - 5 ]. The CDC website provides a recommended immunization schedule for children from birth through 18 years of age, and parents can check with their child's healthcare provider to ensure that their child is up to date on vaccinations [ 1 - 3 ]. However, missed well-child visits (WCVs) have resulted in significant declines in vaccination coverage in children at all milestone ages [ 1 ]. The decline in vaccination coverage has markedly increased the risk of vaccine-preventable diseases in children, including measles, polio, and pertussis [ 1 , 2 ]. Re-prioritizing childhood immunizations and well-visits can prevent the re-emergence of vaccine-preventable diseases, and it is essential that parents and care providers prioritize children's well-child schedule to prevent the rise of pediatric-preventable illnesses in the United States. In addition to that, re-prioritizing childhood immunizations has a far-reaching impact beyond the prevention of vaccine-preventable diseases. This, in turn, can help prevent non-vaccine-preventable diseases by alleviating the burden on healthcare systems, reducing the risk of hospital-acquired infections, and improving overall population health [ 1 - 5 ].

Also, these absences of regular and full body healthcare check-ups for children aged three to five years can lead to undetected health issues, delayed interventions, and potentially fatal consequences [ 2 - 6 ]. This translates into increased medical costs, reduced productivity, and an emotional toll on families. The economic impact encompasses direct medical expenses for treating preventable illnesses, emergency care, and hospitalization, often straining healthcare resources. Moreover, the long-term consequences of inadequate health supervision during these critical developmental years can lead to reduced educational attainment, hindered workforce participation, and a perpetuated cycle of health disparities [ 5 - 8 ]. As a result, investing in and promoting routine healthcare check-up visits for pediatric populations is essential not only for safeguarding the well-being of the younger generation but also for alleviating the economic and social ramifications that arise from preventable disease burdens and loss of life [ 1 - 9 ].

Pediatric WCVs are marked by significant changes in speech and language proficiency, as well as the refinement of fine and gross motor skills. Their burgeoning social interactions and cognitive abilities further underscore the importance of this developmental phase. Regular WCVs during this stage assume a vital role in assessing a child's progress, offering a valuable chance to identify any potential deviations from the expected trajectory and intervene promptly if necessary [ 8 - 10 ].

Moreover, the preschool years witness the emergence of emotional and behavioral skills in children, a domain equally crucial to their holistic development. Within this context, WCVs serve as a platform for healthcare providers to engage with parents, addressing concerns related to behavior, furnishing strategies for managing behavioral obstacles, and discerning subtle signs of emotional or psychological challenges that might warrant attention. Adding to the array of advantages inherent in these WCVs, it is noteworthy that this age range coincides with a critical juncture for immunizations. The routine check-ups between three and five years of age routinely encompass pivotal immunizations that bolster a child's immunity, safeguarding them against a spectrum of severe diseases, and forging a shield of protection that will serve them well into the future [ 3 - 6 , 11 - 14 ].

This comprehensive review analyzes the best practices and guidelines for pediatric WCVs in children aged three to five years. We will explore the importance and benefits of these visits and the components that make up a successful visit. Additionally, we will examine the best practices and potential challenges associated with implementing them and review the guidelines and principles that should be followed during these visits. By doing so, we hope to provide a thorough understanding of the importance of these visits and the relationship between continuity, quality of care, and long-term health outcomes that can guide healthcare providers in delivering the most effective care to pediatric patients, ultimately leading to improved health and well-being in the years to come.

Methods and Materials, and Literature Search

For the present systematic review, an in-depth and comprehensive literature search was conducted on various online databases, including PubMed, Science Direct, Google Scholar, Embase, and Cochrane Library, for peer-reviewed and English-language articles published between 2000 and 2023. The search used various combinations of MeSh terms: “Well child visit,” “well child clinic,” “pediatric healthcare check-up visit,” and “well-baby care,” “preventive care,” and “primary care,” and Boolean operators (AND, OR, NOT) and parentheses to specify various combinations of operations in PubMed, Science Direct, Google Scholar, Embase, Cochrane Library, and HINARI: (1) PubMed (All terms with OR): (“Well child visit” OR “well child clinic” OR “pediatric healthcare check-up visit” OR “well-baby care”) AND (“preventive care” OR “primary care”); (2) Science Direct (Well-child visit and preventive care): (“Well-child visit” OR “pediatric healthcare check-up visit” OR “well-baby care”) AND “preventive care”; (3) Google Scholar (primary care and well-child visit): (Well child visit” OR “pediatric healthcare check-up visit” OR “well-baby care”) AND “primary care”; (4) Embase (Well-child visit and NOT primary care): (“Well child visit” OR “pediatric healthcare check-up visit” OR “well-baby care”) NOT “primary care”; (5) Cochrane Library (Well-child visit OR well-child clinic): (“Well child visit” OR “well-child clinic”) AND (“preventive care” OR “primary care”). We also used exact phrase search, and these combinations allowed us to specify different search criteria related to child healthcare visits, preventive care, and primary care. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Figure Figure1) 1 ) was then used as the preferred guideline for consistency. To locate the articles, we employed keywords that included “well child clinic,” “pediatric healthcare check-up visit,” and “well-baby care,” alongside MeSH terms “preventive care” and “primary care.” The references of the included studies were searched to identify additional articles. The articles sought for were mainly those that analyzed the best practices related to well-child clinic visits, those that explored the significance of such clinical visits, and those that reviewed the components making up successful and effective well-child clinic visit, as well as the best practices and challenges linked to execution of best practices guidelines and principles. The present systematic review has focused on the best practices and guidelines for well-child clinic visit for children aged three to five years. To attain the objectives, the interventions are to be practice-based and applicable to well-child clinic care delivery.

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PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Inclusion and exclusion criteria

For the current systematic review, we excluded studies that had focused on the evaluation of the process of quality improvement in best practices in well-child clinic visits without acknowledging specific practice changes to child care delivery; articles that focused on one topic in well-child care as opposed to tackling the different aspects of well-child clinic practices more generally; articles that were published before 2010 and those that were published in languages other than English, and studies that focused on tackling changes in well-child clinic without tackling the issue of changes in service delivery.

A total of 160 articles were screened for primary screening (title and abstract review) after removing duplicates. Two independent reviewers conducted the initial screening of titles and abstracts to identify potentially relevant articles. After the initial screening, a total of 45 studies were included for secondary screening or full-text review. Full-text articles were obtained for studies that met the initial screening criteria or where there was uncertainty. The full-text articles were then assessed for final inclusion based on the predefined inclusion and exclusion criteria, and, finally, 20 studies were included in this review for data extraction. Data were systematically extracted from the selected studies and assessed using standardized forms to ensure consistency and accuracy.

Consequently, the studies included in this review (Table (Table1) 1 ) were observational studies, randomized controlled trials, and systematic reviews, which included child participants aged zero to five years (with focus on three to five years), and whose findings are directly related to delivery and reception of well-child clinic services, care quality, and child health and development outcomes. We also independently screened the studies and titles with the objective of excluding articles that were duplicated and were irrelevant to the study objectives. The abstracts of studies were also screened using a brief and structured screening tool with the objective of establishing if the selected article satisfied the inclusion criteria, including the topic being studied, the study design, target population, sample size, and study location. We also reviewed the abstract screening outcomes, even as disagreements were solved through general consensus. For the accepted abstracts, retrieval of full texts was conducted, even as a structured form was employed in the extraction of data pertaining to the study design, methodology, results, and findings.

EPDS, Edinburgh Postnatal Depression Scale; PPD, postpartum depression; PRO, patient-reported outcome; RCT, randomized controlled trial; WCC, well-child clinic; WCV, well-child visit

Quality assessment

The assessment of the included studies’ quality was evaluated using the Joanna Briggs Institute quality assessment tool. The tool scores every publication using the frequency scales that were accorded yes, no, unclear, and not applicable responses. The overall quality score of every study was aptly calculated based on the total amount of positive scores received.

An overview of the importance of pediatric well-child visits for children aged three to five years

The importance of a pediatric WCV for children aged three to five years should not be underestimated. These visits provide an opportunity for the physician to screen for medical issues, provide anticipatory guidance, and promote good health for the child [ 6 ]. They also allow primary care physicians to establish a bond with the parents or caregivers and to prioritize interventions with the strongest evidence for good patient-oriented outcomes, such as family social-economic dynamics, assessment and support, and other health-related goals [ 6 ]. Following the U.S. Preventive Services Task Force (USPSTF) and the American Academy of Pediatrics guidelines, immunizations should be updated if necessary, and a one-time vision screening should be carried out between three and five years of age [ 6 ]. Additionally, a head-to-toe examination should be performed, including a review of growth [ 6 ]. During the visit, the physician can answer any questions the parents or caregivers might have and provide age-appropriate guidance [ 6 ]. Furthermore, if any abnormalities are detected, the visit offers the opportunity for further evaluation [ 6 ]. Pediatricians are often parents' main formal counseling source for their children's development and education. Their anticipatory guidance can help improve outcomes in various areas such as infant vocal behavior, parenting skills, infant sleep patterns, parental use of discipline, language development, prevention of falls, home accidents, and auto-passenger injuries [ 7 ]. The WCV is also a chance to use the CDC-recommended growth charts for assessment and to review parent/caregiver-child interactions [ 6 ]. Furthermore, potential signs of abuse should be assessed, and interval growth should be reviewed using appropriate growth charts for height, weight, head circumference, and body mass index [ 6 - 7 ]. Moreover, primary care providers are well-positioned to engage parents and provide referrals to community services during WCVs [ 8 ]. Table Table2 2 shows an overview of the main components of a WCV.

Benefits of a well-child visit for young children

The benefits of WCVs for young children are numerous [ 8 , 9 ]. WCVs enable pediatricians to review a patient's health history, track a child's growth and development, and provide guidance for parents around topics such as nutrition, sleep, and behavioral development [ 10 , 11 ]. Furthermore, studies have shown that the length of a WCV is linked to the amount of unmet needs experienced by a family [ 12 , 13 ]. This is especially pertinent for children with chronic illnesses or special healthcare needs [ 12 ], as pediatric visits are more likely to result in hospital admission than adults [ 14 ]. Additionally, WCVs provide an opportunity to discuss prevention, as in the case of childhood obesity [ 15 ]. To ensure that WCVs are valuable, there should be an agreement between parents and medical professionals about the visit's goals [ 7 ]. Furthermore, physicians should discuss topics such as when to introduce solid foods [ 6 ], as this has implications for a child's long-term health. As a result, WCVs can be incredibly beneficial to young children and their families.

Components of a well-child visit for children aged three to five years

This analysis also provided details of the topics discussed during the visits. These topics were classified into seven categories: secondary prevention, primary prevention, health promotion, development, education, and those focused on the parents and family relationship [ 7 ]. The study was based on 49 visits to five pediatricians for children aged three to five years [ 7 ]. The results showed that the major topics discussed during the visits were illness prevention and education, followed by physical examination and development. Other topics such as health promotion, safety, nutrition, and emotional and mental health were also discussed but in lesser amounts. These results suggest that pediatric providers focus on the primary aspects of a child's physical and mental health, although other topics are often included in the visit. However, this study did not provide specific information about the components of a WCV for children aged three to five years [ 7 ]. This means that it is still necessary to understand the specific topics discussed during a WCV to effectively assess a child's health. Therefore, further studies are needed to provide more information about the components of a WCV for children aged three to five years.

Best practices for pediatric well-child visits

A recent study assessed the effectiveness of the Improved Care for Moms and Babies (ICC) model on maternal depression screening and other health behaviors discussed during pediatric WCVs. The study gathered information from mothers who had accompanied their children to WCVs at ages 12 and 24 months [ 15 ]. The survey included questions about health history, behaviors, and whether the physician discussed maternal depression, tobacco use, family planning, and folic acid supplementation [ 16 ]. The results of the study showed that the ICC model had improved the way maternal depression was being addressed during WCVs. However, best practices for screening, referral processes, and documentation related to PPD screening during WCVs still require further study [ 17 ]. This is especially important, as screening for postpartum depression in mothers is recommended during WCVs for young children [ 17 ].

Best practices implemented in a well-child visit

Best practices for WCVs are those that provide the most patient-oriented outcomes, such as immunizations, postpartum depression screening, and vision screening [ 18 ]. The American Academy of Pediatrics has created guidelines for WCVs, known as the periodicity schedule, and they recommend scheduled WCVs [ 19 ]. A study was conducted to determine the impact of the intervention on illness visits between WCVs [ 10 ]. The results showed that there were few differences between the two study arms, but a chart review showed that intervention children had fewer illness visits [ 10 ]. Pediatric WCVs also provide an opportunity to address psychosocial issues and developmental assessments [ 20 , 21 ], and there is wide variation in practice patterns regarding screening [ 22 ]. As far as the duration of WCVs, they are usually short; therefore, strategies for addressing the time devoted to WCVs must be considered [ 23 ]. Finally, it is important to understand the best practice of screening, education, and referral processes for addressing psychosocial issues during WCVs [ 16 ], as they are a significant part of pediatric office visits [ 24 ].

Potential challenges to implementing these best practices in a well-child visit

Additionally, the potential challenges to implementing best practices in a WCV must be acknowledged [ 18 ]. For instance, the lack of evidence-based practices can lead to uncertainty about how best to use the limited time available [ 23 ]. Furthermore, the Committee on Practice and Ambulatory Medicine of the American Academy of Pediatrics has offered a periodicity schedule to recommend scheduled WCVs [ 19 ]. In a study to assess the differences between the interventions and the control arms, it was found that children in the intervention group had fewer illness visits between WCVs than control children [ 10 ]. This points to the importance of further understanding best practices for screening, education, and referral during the WCVs [ 16 ]. In this regard, research has revealed that 11.6% of the 483 WCVs were with children between 18 and 36 months of age [ 24 ]. Moreover, wide variations in practice patterns have been observed with some using a parent questionnaire for all WCVs and some using formal screens only at specific ages [ 22 ]. In addition, there is growing interest in understanding the practices of pediatric well-child care internationally [ 21 ] and exploring promising strategies for screening during WCVs [ 17 ]. Finally, there is a need to consider the ethical and legal dimensions of the boundaries of pediatric care [ 20 ].

Guidelines and principles for pediatric well-child visits

The subject of pediatric WCVs has been studied, and a number of guidelines have been developed to ensure that young children receive the best care. Studies have looked into adherence to pediatric WCV recommendations [ 25 ], and the standards and principles of Bright Futures [ 26 ]. In addition, similarities in approach to child health with periodic visits and anticipatory guidance have been seen abroad [ 21 ]. Guidelines recommend scheduled WCVs, detailing the schedule and content of care [ 19 ]. This includes preventive care such as guidance directed by a physician [ 27 ], and screening tests such as hearing screening [ 28 ]. However, further work is needed to optimize well child care [ 29 ], and a study found that a schedule with fewer visits had no detrimental effect on child health [ 30 ]. Pediatric WCVs are essential for the health and well-being of children, and research has been conducted to ensure that these visits are up-to-date and provide the best possible care.

Implementing guidelines and principles in a well-child visit

Therefore, the implementation of established guidelines and principles for WCVs is necessary [ 25 ]. The standards and principles of Bright Futures and the American Academy of Pediatrics [ 26 ] are similar in their approach of providing periodic visits and anticipatory guidance [ 21 ]. These guidelines and principles are used to define the schedule and content of well-child care [ 19 ], which includes guidance directed by a physician and preventive issues [ 17 ]. For example, screening tests for children who cannot fully participate are recommended [ 28 ]. Furthermore, research has shown that a schedule with fewer visits has no detrimental effect on child health [ 30 ]. Even though these articles provide a proof of principle, additional work is necessary to optimize well-child care [ 20 ]. Table Table3 3 shows an overview of the basic principles fostering a WCV.

Potential challenges to implementing these guidelines and principles in a well-child visit

Challenges to implementing effective WCV guidelines and principles arise from multiple areas [ 25 ]. For instance, the adherence rate of WCV recommendations may be lower for certain children [ 26 ]. Various countries have a similar approach to child health, focusing on periodic visits and anticipatory guidance [ 21 ]. The principles of prevention that shape WCV can vary depending on the country [ 19 ]. WCV is the most common type of physician visit for children, and it typically involves guidance from a physician [ 27 ]. For example, some children may have difficulty participating in screening tests [ 28 ]. In addition, further work is needed to optimize WCV, and research has suggested that a schedule with fewer visits may not have a detrimental effect on child health [ 29 ]. While there are suggested approaches for WCV programs, these are intended to be illustrative principles rather than specific programs [ 30 ]. As such, there are multiple potential challenges to implementing WCV guidelines and principles that must be carefully considered.

Study strengths and limitations

The research conducted in this study possesses several strengths. Firstly, the systematic review follows the PRISMA guidelines, ensuring a rigorous and transparent approach to study selection, data extraction, and synthesis. The search strategy utilized a range of global databases, including Web of Science, EMBASE, PubMed, Cochrane Library, HINARI, and Google Scholar, as well as reference list searches, minimizing the risk of missing relevant studies and enhancing the comprehensiveness of the review. The use of Boolean operators and specific keywords contributes to the thoroughness of the search process; however, the debate surrounding the replication of search results using mesh terms, Boolean combinations, and parentheses for precise literature retrieval stems from concerns about sensitivity and specificity. This debate continues due to factors such as the publication rate, retractions in online scholarly articles, and limitations in search algorithms. Additionally, the focus on studies published within a specific timeframe (2000-2023) enables the inclusion of recent and up-to-date evidence, relevant to the current landscape of acute gout treatment. The evolution and progression of best practices in pediatric well-child clinic visits from 2000 to 2023 have been influenced by advancements in healthcare, changes in technology, evolving clinical guidelines, and a growing understanding of child development and preventive care. The systematic approach to data extraction and quality assessment, including the use of the Joanna Briggs Institute quality assessment tool, enhances the credibility of the findings and the overall reliability of the review. Moreover, the analysis of both monotherapy and combination therapy approaches provides a comprehensive understanding of their respective impacts on serum urate levels, gout symptoms, and overall management. By evaluating various outcomes such as serum urate levels, tophi, gout flare rates, and urinary uric acid, the study contributes a holistic perspective on the effectiveness of the different treatment strategies. Overall, these methodological strengths support the reliability and validity of the conclusions drawn from the research.

However, there are some limitations. Firstly, the scope of included studies is limited to those published between 2000 and 2023, potentially excluding relevant earlier studies that could contribute valuable insights to the topic. Moreover, the inclusion criteria focus on observational studies with specific designs and geographic restrictions, which might omit relevant experimental or international studies that could provide a more comprehensive perspective on the subject matter. Secondly, the diversity in methodologies, patient populations, and study quality across the included studies introduces heterogeneity, which can lead to inconsistencies in findings and complicate direct comparisons between the studies. Despite the use of the Joanna Briggs Institute quality assessment tool, variations in study quality could influence the reliability and robustness of the conclusions drawn from the review. Finally, the search for studies was confined to a selection of global databases and conducted exclusively in English. This approach may introduce publication bias; favoring studies with significant findings and excluding studies published in other languages may limit the representation of findings from non-English-speaking regions, ultimately affecting the generalizability of the conclusions derived from the research.

Conclusions

Pediatric WCV for children aged three to five years is a vital part of preventive healthcare, addressing physical, emotional, cognitive, and social development. Evidence-based practices ensure comprehensive assessments, vaccinations, developmental screenings, and guidance, thus nurturing a healthy future. These visits benefit immediate and long-term well-being, enhancing individual and community health.

This review emphasizes the importance of WCVs in screening for medical issues, providing guidance, and promoting health. It underlines bonding between physicians, parents, and caregivers, prioritizing evidence-based interventions. Immunizations and socio-dynamic support are highlighted, emphasizing their relevance in WCVs. These visits also offer opportunities for answering parental questions and giving age-appropriate advice. However, challenges exist in implementing guidelines, especially for children with chronic conditions. Primary care providers are essential in engaging parents and linking them to community services, improving outcomes in areas such as vocal behavior, parenting, and language development.

Further research is required to assess individual components' effectiveness in these visits and address implementation challenges, especially for children aged three to five years. In conclusion, policy changes are crucial to underscore the significance of WCVs and ensure that best practices are consistently followed. These changes can lead to better health outcomes, increased vaccination coverage, improved parental education, and reduced healthcare disparities, ultimately benefiting children and communities as a whole.

Acknowledgments

O.E.O. contributed to the conceptualization of this project and the acquisition of the pieces of literature, played several roles in analyzing the collated works of literature, carefully reviewed them for the correctness of the intellectual content, agreed to be accountable for all aspects of the integrity of the work, and approved the final version. P.F.A. contributed to the design of this work, played a role in the interpretation of the collated literature and writing parts such as the introduction, discussion, and other parts, reviewed it for intellectual accuracy, agreed to be accountable for its integrity and will answer any question that may arise, and provided final approval of the final draft. O.B.N. played a role in creating the manuscript design, collating the works of literature used, analyzing the kinds of literature used, drafting parts of the body and conclusion, agreeing to be responsible for the intellectual accuracy and validity of the work, answering the ensuing questions, and authorizing the final version. T.O.E. substantially contributed to this study concept, was involved in analyzing the collated literature that was reviewed, reviewed its scientific content for correctness, drafted part of the abstract and body, agreed to be accountable for its integrity and to resolve any unfolding issues, and then approved its final version. O.O.A. significantly contributed to the creation of this manuscript by playing a role in the conceptualization, ensuring it was critically reviewed for intellectual content and accuracy, agreeing to resolve any unfolding queries about the work and its integrity, and finally approving the final draft. KPO: played a role in conceptualizing this study; reviewed, analyzed, and drafted parts of the body of the work; ensured its intellectual content is worthy of publication; agreed to be accountable for its integrity and to resolve any queries that may arise; and finally approved the final version. IUI: In addition to conceptualizing and designing the manuscript, this author played a role in synthesizing the works of literature, analyzing the content, creating parts of the original drafts, reviewing subsequent drafts for their intellectual validity and content, agreeing to be accountable for all aspects of the work, and finally approving its final version.

The authors have declared that no competing interests exist.

See which popular national parks are requiring reservations for summer 2024

Every year, it seems that more national parks are requiring timed-entry reservations . Sometimes, it’s just to drive into a park . Other times, it’s for specific, sought-after activities .

This summer is no different, with Mount Rainier and Yosemite joining the mix. The requirements add an extra step and expense for travelers, but they’re not meant to be a hurdle.

“The timed entry system reservation system is not to limit visitation but to spread it out more equitably throughout the day,” Mount Rainier National Park ranger Terry Wildly told USA TODAY in February.

In the past, she said visitors had to wait up to three hours just to enter the popular park, and some caused lasting damage to meadows when venturing off-trail to avoid crowds.

As Mount Rainier rolls out reservations this summer, here’s what other park visitors should know.

How many national parks have timed entry?

Only a fraction of America’s 63 national parks require timed-entry reservations or permits for particularly popular experiences. In most cases, they’re only for certain portions of the park during the busiest times of day.

◾ Acadia National Park will require timed-entry reservations for vehicle access to Cadillac Summit Road from May 24 through Oct. 22. There are two types of reservations, Sunrise and Daytime, with varying restrictions. Each reservation costs $6 per vehicle and may only be purchased online, not in the park. A separate $35 vehicle entry fee is also required for the park.

◾ Arches National Park requires timed-entry reservations for all vehicles entering the park between 7 a.m. and 4 p.m. through Oct. 31. Timed-entry tickets cost $2. A separate vehicle entry fee of $30 is also required.

◾ Glacier National Park will require timed-entry reservations for vehicles accessing North Fork and Going-to-the-Sun Road from the West Entrance between 6 a.m. and 3 p.m. from May 24 through Sept. 8. Reservations will not be required for vehicles entering Going-to-the-Sun Road from the St. Mary Entrance nor will they be required for Two Medicine, like they were last year. However, they will still be required for Many Glacier between 6 a.m. and 3 p.m from July 1 through Sept. 8. Each type of reservation costs $2. A separate $35 vehicle entry fee is also required for the park.

◾ Haleakalā National Park requires reservations year-round for visitors who want to watch sunrise from the summit. Summit sunrise reservations cost $1 and are required for every vehicle entering the park between 3 a.m. and 7 a.m. A separate $30 vehicle entry fee is also required for the park.

◾ Mount Rainier Natonal Park , for the first time, will require timed-entry reservations for two of its most popular areas: Paradise Corridor from May 24 through Sept. 2 and Sunrise Corridor between July 3 and Sept. 2. Reservations will only be needed between 7 a.m. and 3 p.m. Each type of reservation will cost $2. A separate $30 vehicle entry fee is also required for the park.

◾ Rocky Mountain National Park will require timed-entry reservations to access most roads between 9 a.m. and 2 p.m. from May 24 through Oct. 14. Visitors who also want to access the park’s busy Bear Lake Road will need a specific type of reservation, Timed Entry+, between 5 a.m. and 6 p.m. from May 24 through Oct. 20. Timed Entry+ covers all park roads. Both types of reservations cost $2.

◾ Shenandoah National Park requires day-use tickets to hike Old Rag Mountain through Nov. 30. Tickets cost $2 per person and can be reserved 30 to 5 days in advance. The day-use tickets are separate from the park’s $30 vehicle entry fee .

◾ Yosemite National Park now requires reservations for vehicles entering the park between 5 a.m. and 4 p.m. on certain days. Through June 30 and between Aug. 17 and Oct. 27, they’ll only be required on weekends and holidays. But they’ll be required every day from July 1 through Aug. 16. Peak hour reservations cost $2, on top of the $35 vehicle entry fee for the park.

◾ Zion National Park is continuing to pilot its permit system for its popular Angels Landing hiking trail. Permits can be obtained through a seasonal lottery or daily lottery on Recreation.gov. Lottery registrations costs $6 for up to 6 people for each lottery. Permits cost $3 per person. That’s on top of the $35 vehicle entry fee for the park.

When can I make park reservations?

Dates vary by park, but all national parks book reservations through Recreation.gov .

The great outdoors next door: Hot to find hiking, camping, more near you

Which national parks in Utah require reservations?

Of Utah’s “ Mighty 5 ” national parks, only Arches requires reservations for park entry.

Do you need reservations to get into Zion National Park?

No. Reservations are not required to enter Zion, just permits to hike Angels Landing.

Can I get into RMNP without a timed entry?

Yes. Rocky Mountain National Park’s timed-entry requirements don’t begin until May 24. Even after that, reservations will only be required during peak hours.

Are reservations required for Yellowstone?

No. Yellowstone does not require timed-entry reservations. However, permits are required for specific recreational activities , such as backcountry camping and boating.

Southwest will limit hiring and drop 4 airports after loss. American Airlines posts 1Q loss as well

American and Southwest airlines both say they lost money in the first quarter, and they're responding by trying to cut costs

DALLAS -- Southwest Airlines will limit hiring and stop flying to four airports as it copes with weak financial results and delays in getting new planes from Boeing.

Both Southwest and American Airlines reported first-quarter losses Thursday. Demand for travel remains strong, including among business flyers, but airlines are dealing with higher labor costs, and delays in getting new aircraft from Boeing are limiting their ability to add more flights.

Southwest said it lost $231 million. CEO Robert Jordan said the airline was reacting quickly “to address our financial underperformance," including by slowing down hiring and asking employees to take time off.

The Dallas-based carrier said it expects to end this year with 2,000 fewer employees than it had at the start of the year.

In August, Southwest will stop flying to four airports: Cozumel, Mexico; Syracuse, New York; Bellingham, Washington; and George Bush Intercontinental Airport in Houston, where the airline’s major operation is at smaller Hobby Airport. Southwest hasn't left an airport since 2019, when it pulled out of Newark, New Jersey, and consolidated its New York City-area flying at LaGuardia Airport.

Southwest will also trim flights in Atlanta and at O’Hare Airport, which augments the airline's main Chicago service at Midway Airport.

The moves will help the airline focus on more profitable locations and deploy a fleet of planes that will be smaller than it had planned. Southwest said it expects to get only 20 new 737 Max 8 jets from Boeing this year, down from the 46 it expected just a few weeks ago. It will offset some of the shortage by retiring fewer planes.

Boeing is struggling with slower production since a door plug blew out of an Alaska Airlines Max 9 in January, and that is frustrating its airline customers.

Dallas-based Southwest said that its loss, after excluding special items, was 36 cents per share. That was slightly worse than the loss of 34 cents per share that Wall Street expected.

Revenue rose to $6.33 billion, below analysts' forecast of $6.42 billion.

American said it lost $312 million as labor costs rose 18%, or nearly $600 million. The airline said it expects to return to profitability in the second quarter — a busier time for travel — and post earnings between $1.15 and $1.45 per share. Analysts expect $1.15 per share, according to a FactSet survey.

The first-quarter loss amounted to 34 cents per share excluding special items, which was worse than the loss of 27 cents per share forecast by analysts.

Revenue was $12.57 billion.

CEO Robert Isom said American is less impacted by Boeing's problems because the airline had already received hundreds of new planes in recent years. The airline said eight Boeing jets it expected to get won't show up this year as planned. American has ordered Boeing Max 10s, a larger model that has not yet been certified by the Federal Aviation Administration, but those planes are not due until 2028.

“I've talked to everyone at Boeing that I can possibly address and the message is the same: Get your act together,” Isom said on a call with analysts and reporters. “It starts with producing quality products one at a time off the assembly line ... I can't tell you if they're making progress or not.”

American has had no problem getting new, smaller regional jets from Embraer. Isom said the Brazilian manufacturer has been “incredibly reliable.”

Shares of Southwest fell more than 7% in midday trading, while American was down 1%.

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Nov 18, 2023; Tempe, Arizona, USA; Oregon Ducks offensive lineman Jackson Powers-Johnson (58)

NFL Draft: Jackson Powers-Johnson, Long-Term NFL Starter?

NFL Draft Prospect Profile: Oregon Ducks Center Jackson Powers-Johnson

Author: Grant Afseth

In this story:

Former Oregon Ducks center Jackson Powers-Johnson projects as an intriguing prospect ready to join the professional ranks in the 2024 NFL Draft. He's considered a versatile offensive line prospect capable of playing different positions.

Powers-Johnson, a center with a solid build and exceptional upper-body strength, compensates for his shorter reach. Although he struggles with bending at the knees, affecting his leverage, Powers-Johnson effectively uses his strength to manipulate opponents at the line of scrimmage.

Known for his intense competitiveness and tough demeanor, he needs to refine his initial technique to maintain blocks consistently. Despite possessing average athleticism, Powers-Johnson excels in pass protection due to his vigilant approach, stable stance, and disciplined technique. While his first NFL season may present challenges if he starts immediately, his potential suggests he could develop into a reliable long-term starter.

Oregon Legacy

Nov 18, 2023; Tempe, Arizona, USA; Oregon Ducks offensive lineman Jackson Powers-Johnson (58)

Mark J. Rebilas-USA TODAY Sports

Jackson Powers-Johnson left a distinguished legacy at the University of Oregon , setting milestones as the first Duck and Pac-12 player to win the Rimington Trophy, awarded to the nation’s best center. His accomplishments include being named a unanimous All-American, with first-team honors from the AFCA, Associated Press, FWAA, Sporting News, and Walter Camp.

Powers-Johnson excelled throughout the season, starting the first 13 games before opting out of the Vrbo Fiesta Bowl to prepare for the NFL Draft. According to Pro Football Focus, he led all FBS centers in both overall and run-blocking grades and was second in pass-blocking. Remarkably, he allowed just one pressure and no sacks in 471 pass-blocking opportunities.

Pro Comparisons

Powers-Johnson was compared to Quinn Meinerz by NFL.com, who has played guard for the Denver Broncos since being selected with the No. 98 overall pick in the 2021 NFL Draft.

NFL Draft Projections

The current projection for Powers-Johnson is to be selected in Rounds 1-2.

What Powers-Johnson Is Saying

In an exclusive interview with DucksDigest 's Bri Amaranthus, he said that no matter what position he is tasked with playing in the NFL, his "violent" approach will help him be successful.

"I play violently and I think that translates to the league really well," Powers-Johnson said.

What Nation Is Saying

One NFC scouting director told NFL.com that Powers-Johnson’s intangibles resemble a starting center in the NFL.

“He’s tough, smart and strong. I just don’t overthink it with centers. When you get those elements, you usually have a starter.” - NFC scouting director

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New visits to understand how well children with SEND are prepared for adulthood

New guidance from Ofsted and the Care Quality Commission (CQC) for visits looking at how children and young people with special educational needs and/or disabilities (SEND) are being prepared for adulthood.

Ofsted and the CQC have today published guidance for the next series of thematic visits looking at how children and young people with special educational needs and/or disabilities ( SEND ) are being prepared for adulthood.

As part of the area SEND inspection arrangements, Ofsted and the CQC will carry out a series of in-depth reviews to explore a particular aspect of the SEND system between spring and summer 2024.

Read the ‘Thematic reviews of preparation for adulthood arrangements in local areas’ guidance.

The visits will consider all phases of a child with SEND ’s transition to adulthood, from early years settings through to post-16 education, to get an in-depth picture of how preparation for adulthood ( PFA ) arrangements are working. These arrangements include any support delivered by local area partners across education, health and social care that focuses on the 4 key pathways for preparation for adulthood based on the ‘ SEND code of practice’ – employment, independent living, community inclusion and health.

Ofsted and the CQC will explore how local area partners work together to make sure their decisions are focused on young people’s interests and aspirations. Evidence will be gathered from key stakeholders, including children and young people with SEND and their families. Inspectors will consider a range of topics including:

how young people with SEND are being supported to achieve their full potential. For example, through further education or supported internships
how young people with SEND are empowered to make decisions for themselves and live as independently as possible
how children and young people with SEND are supported to participate in society
how children and young people with SEND are supported to be as healthy as possible in adulthood
how local area partners work together to develop and implement strategies for PFA
the enablers and barriers to effectively preparing young people with SEND for adulthood

Lee Owston, Ofsted’s National Director for Education:

The current SEND system is not meeting the needs of too many children and their families. It is vital that every child is provided with the support and guidance they need to thrive and live as independently as possible throughout their adult lives. I hope that these visits provide valuable insight into how we can improve the experiences of children with SEND as the government develops its SEND and alternative provision improvement plan.

Nigel Thompson, Deputy Director of Multiagency Operations at the Care Quality Commission:

When children, young people and their families face times of transition it is not only vital that services understand their needs, but also that those children, young people and their families are involved in and prepared for the change. Looking at people’s experiences alongside Ofsted, we will be able to explore how agencies and health care providers are working together – where improvements can be made and share good practice.

Notes to editors

Findings from the visits will be shared in a single national report in autumn 2024. This report will list all the areas visited but won’t attribute findings to individual areas unless the area agrees to be identified.
The visits will not result in judgements about local areas. The overarching report will highlight examples of good practice and identify any systemic concerns. Where good practice is identified, this will be shared with the Department for Education and the Department for Health and Social Care to support their development of policy for the SEND and alternative provision improvement plan.

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Trump Visits a Construction Site in Manhattan Before His Trial Resumes

The early morning campaign stop exemplifies the balancing act required for a candidate who is also a criminal defendant.

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Former President Donald J. Trump, center, in a crowd. People are reaching at him. Some are holding or wearing red hats.

By Michael Gold

April 25, 2024, 9:21 a.m. ET

Hours before he was set to return to the courthouse for his criminal trial in Manhattan, former President Donald J. Trump started Thursday morning by visiting a construction site in a campaign stop that exemplified the balancing act required for a candidate who is also a criminal defendant.

In the shadow of what will eventually be the 70-story headquarters of one of the nation’s biggest banks, Mr. Trump shook hands with union workers in a visit meant to highlight his support from working-class voters and draw attention to his criticism of President Biden’s economic policies.

His warm reception — a cheering crowd of roughly 100 people gathered behind him, chanting “we want Trump” — marked a stark contrast from the sober environment of the courthouse where Mr. Trump has spent most weekdays since his trial began last week, and where his comments have largely been limited to addressing reporters in the hallway during breaks.

Mr. Trump has not held a rally since just before the trial began, in part because a planned event in North Carolina last weekend was canceled because of weather. But his visit to the construction site typifies how his campaign is using retail stops in New York, a left-leaning state not expected to be in play in November, to help broadcast his national message.

“I have a lot of support here,” Mr. Trump said, as roughly two dozen workers clambered up scaffolding and equipment to catch a glimpse of him. Among those in the crowd were members of the Teamsters union, whose endorsement Mr. Trump has been courting.

The trip to the construction site kicks off what will be a significant day in Mr. Trump’s legal battles. In Manhattan, where Mr. Trump is accused of falsifying business records, David Pecker, the former publisher of The National Enquirer, is expected to return to the stand and detail the hush-money payment at the center of his case. Asked by reporters, Mr. Trump said that Mr. Pecker had been “very nice” and called him a “nice guy.”

In Washington, the Supreme Court will consider Mr. Trump’s argument that he is immune from prosecution on federal charges that he plotted to subvert the 2020 election. Mr. Trump, who will likely be in the Manhattan courtroom during the oral arguments before the Supreme Court, repeated an argument he has been making for months that “a president has to have immunity, otherwise you just have a ceremonial president.”

Mr. Trump’s appeal to working-class voters was key to his victory in 2016, and as he tries to return to the White House, he has been eager to win the support of rank-and-file union members and to drive a wedge between them and labor leaders who have long favored Democrats.

In January, Mr. Trump met with the Teamsters union’s executive board and said he believed he had a “good shot” at securing the influential union’s endorsement. The union endorsed Mr. Biden in 2020, and its leaders met with the president last month.

Mr. Biden has for years touted his allegiance to unions. On Wednesday he received the endorsement of the North America’s Building Trades Unions, an umbrella group whose leaders pointed to Mr. Biden’s bipartisan infrastructure package.

Jason Miller, a senior Trump campaign adviser, said that Thursday’s visit had been “on the books for some time” and was part of the campaign’s larger strategy to contend with the scheduling challenges posed by the Manhattan trial.

“Since the Biden Trials are an attempt to keep us off the campaign trail, we’ll bring the campaign trail to us,” he said. Mr. Trump has said without citing evidence that the charges are part of an “election interference” scheme orchestrated by Mr. Biden.

Michael Gold is a political correspondent for The Times covering the campaigns of Donald J. Trump and other candidates in the 2024 presidential elections. More about Michael Gold

Our Coverage of the Trump Hush-Money Trial

News and Analysis

Prosecutors accused Donald Trump of violating a gag order four additional times , saying that he continues to defy the judge’s directions not to attack witnesses , prosecutors and jurors in his hush-money trial.

Trump’s criminal trial in Manhattan is off to an ominous start for the former president, and it might not get any easier in the days ahead. Here’s why.

The National Enquirer was more than a friendly media outlet for Trump’s presidential campaign in 2016. It was a powerful, national political weapon that was thrust into the service of a single candidate , in violation of campaign finance law.

'We are required to support our allies': Keating visits Ukraine after House vote

As a multibillion dollar aid package for Ukraine loomed on the near horizon, a bipartisan group of four lawmakers from the U.S. House of Representatives visited the Eastern European nation Monday as a diplomatic effort to reinforce U.S. support ahead of an expected Russian military offensive, U.S. Rep. William Keating , D-Massachusetts, told the Times on Tuesday.

The group, which included two Republicans and two Democrats, met with several high-ranking Ukrainian officials, including the Minister of Defense, pro-government reform groups, anti-corruption officials and Ukrainian President Volodymyr Zelenskyy .

Following a phone call the Ukrainian president took with U.S. President Joe Biden, Keating said the group met with Zelenskyy for nearly an hour. Keating said Ukraine is in the midst of a “crisis point” in their war with Russia, as money, munitions and other vital military supplies run low.

“They’ve just been completely outgunned,” Keating said. “It isn’t a lack of determination or courage, they’re just lacking the ammunition.”

Keating represents the 9th Congressional District , which includes the Cape and Islands, South Coast, and South Shore.

Keating: Low munitions in a 'very hot war'

Hours before the visit with Zelenskyy, the House voted to push a roughly $60 billion dollar aid package for Ukraine through to the U.S. Senate. As of Tuesday afternoon, the bill had the majority necessary to clear the chamber in a final vote.

The Senate later on Tuesday approved a package that would funnel $60 billion to support Ukraine, $17 billion for Israel, $9 billion in humanitarian aid for Gaza and elsewhere , and $8 billion for allies in the Indo-Pacific — with a bipartisan 79-18 vote. President Joe Biden was expected to swiftly sign the legislation into law.

Zelenskyy was relieved that the House package went through, Keating said. “It was just days before, that he was in a very hot war where the Russians were pushing them back and the munitions ratio was 10-to-1 in favor of the Russians.”

Additional aid for Ukraine has been a polarizing issue for Republicans and Democrats alike. Supporters of aid stress the importance of defending global allies of the U.S. in the face of rising authoritarianism and the threat of additional military conflict. Opponents in the U.S. point to a need to address domestic issues such as securing the country's southern border and dealing with inflation.

Keating said the aid package is a strategic victory in the ongoing conflict in Ukraine, sending an important message to Russian President Vladimir Putin and strengthening Ukrainian resolve.

“Every single military person I've spoken to, that’s on our side, said it's pay less now or pay more later,” Keating said, referring to Putin’s intention of bringing other former-Soviet satellite states back into the Russian fold. “We are required to support our allies.”

Walker Armstrong reports on all things Cape and Islands, primarily focusing on courts, transportation and the Joint Base Cape Cod military base. Contact him at [email protected]. Follow him on Twitter: @jd__walker.

The Cape Cod Times is providing this coverage for free as a public service. Please take a moment to support local journalism by subscribing.

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Well-Child Visits and Recommended Vaccinations
The Vaccines for Children (VFC) program provides vaccines to eligible children at no cost. This program provides free vaccines to children who are Medicaid-eligible, uninsured, underinsured, or American Indian/Alaska Native. Check out the program's requirements and talk to your child's doctor or nurse to see if they are a VFC provider.
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Your Child's Well Visit: What Parents Need to Know
In the world of pediatric care, a well visit is the equivalent of what used to be called a check-up or a physical. Once a year, parents typically make an appointment for a well visit with their family physician or pediatrician to make sure all's well with their child and to voice any concerns. For children 3 and under, though, visits are as frequent as every few weeks in the
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MLN6775421
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Catch Up on Well-Child Visits and Recommended Vaccinations

Well-Child Visits and Recommended Vaccinations Are Essential

Routinely Recommended Vaccines for Children and Adolescents

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AAP Schedule of Well-Child Care Visits

Schedule of well-child visits

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Your Child’s Well Visit: What Parents Need to Know

What is generally included in a well visit?

How should I prepare for my child’s well visit?

What should I bring?

What, exactly, will take place during the visit?

At an infant well visit, your doctor will:

If your child is a toddler , your doctor will also:

During a school-age well check , your doctor will ask questions about the following:

During a teen well visit , your doctor— optimally, someone your teenager feels comfortable with—will :

What if I need to ask the doctor about a specific medical issue?

What does a follow-up or “sick” visit entail?

Can I combine my child’s well visit with a non-routine or sick office visit?

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Ages 12 to 18 Months

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By age 18 months, most kids:

Ages 24 to 30 Months

By age 30 months, most kids:

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By age 4 years, most kids:

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