Adult Preventive Care Flow Sheet Page 2
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2ADULT PREVENTITIVE CARE FLOW SHEET
For Men:
Testicular Exam
Annually
Date
Annually
Results
Prostate Screening
Every 1-2 years after
Date
age 40
Results
Suggested Result Codes: O=ordered N=Normal A=Abnormal R=Refused E=Done Elsewhere *=Next Due D=done
Adult Immunizations:
Tetanus – Diptheria
Every 10 years
Date
(Td)
Results
Influenza
Annually
Date
Results
Pneumococcal
Age 65 years
Date
Results
MMR
Date
1-2 doses if
unvaccinated
Results
Varicella (Chicken Pox) 2 doses 4-8 weeks
Date
apart without
Results
evidence of immunity
Zostavax
Age 60 years and
Date
over
Results
HPV (Human
Women ages 19 to
Date
Papillomavirus)
26 years
Men ages 19 to 21
years (if not
Results
completed when
younger)
Rev 01/2017
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