Adult Preventive Care Flow Sheet

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ADULT PREVENTITIVE CARE FLOW SHEET
Name:
DOB:
Adv. Directives discussed:
Yes
No
Year
Age
Date
Drugs/Alcohol (D)
Physical Activity (A)
Types
Estrogen (E)
Sexual Behavior (S)
Date
Folic Acid (F)
Tobacco (T)
Types
HIV/AIDS (H)
UV Exposure (U)
Date
Types
Injuries (I)
Violence/Guns (V)
Nutrition (N)
Preconception (P)
Date
Mental Health (MH)
Glaucoma Ref. (GR)
Types
Medications (M)
Dental Health (DH)
Date
Types
Minimum Frequency
Height
Annually
Date
Weight
Results
Blood Pressure
Every medical
Date
encounter/or at least
annually
Results
BMI
Annually
Date
Results
TB Risk
Upon initial H&P
Date
Assessment
Result
s
Cholesterol
Date
Men 35> Women
45> and anyone at
high-risk for CAD
Results
>20
Date
Colonoscopy
Age 50 and every 10
years or annual fecal
occult blood test
Results
(FOBT) plus
sigmoidoscopy every
5 years
Skin Cancer
Annually
Date
Screening
Results
For Women:
Date
Clinical Breast
Yearly after age 40
Exam
Results
Mammography
Annually after age 50
Date
Results
Date
Pap Smear
Every 3 years
age 21-65
Results
Annually screening
Date
Chlamydia
for sexually active 25
Results
years and older if at
risk
Rev 01/2017

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