New Patient History Form Page 3
ADVERTISEMENT
1
2
3
4Provider Signature: __________________________________________
Date: ______________________
PRAIRIESTAR HEALTH CENTER – YOUR MEDICAL HOME
Health Maintenance – Preventative Care History
(New Patients Establishing Primary Care)
**Preventive care is the most important step you can take to manage your health, because many of the top
risk factors leading to illness and premature death are preventable.
Your provider will recommend preventive care screening tests depending on your overall health, family history,
your gender, and your age. These screening tests will help your provider spot problems. Early detection often
means a better outcome for you and lower health care costs.
Even if you have a chronic condition such as diabetes, high blood pressure, high cholesterol or other medical
problems, there are steps your provider can recommend that may reduce symptoms and improve your quality of
life.
**Please complete chart below to the best of your ability by filling in the dates. We will work together to get
you on a schedule for preventative health that best meets your individual needs and health goals.
VACCINATIONS
DATE LAST DONE
WHO NEEDS
HOW OFTEN
Tetanus vaccine***
everyone
every 10 yrs
Flu vaccine
everyone
yearly
Pneumonia vaccine***
everyone at age 65
once
Shingles vaccine
everyone at age 60
once
HPV vaccine
everyone age 11-26
3 in series
WOMEN
DATE LAST DONE
WHO NEEDS
HOW OFTEN
Colonoscopy***
everyone 50 and over every 1-10 yrs
Pap Smear***
women 21-65
every 3-5 yrs
Mammogram
women 40-85
every 1 yr
Breast Exam
women 18-85
every 1 yr
Bone Mineral Density***
women 65 and over
every 2 yrs
MEN
DATE LAST DONE
WHO NEEDS
HOW OFTEN
Colonoscopy***
everyone 50 and over every 1-10 yrs
PSA and/or Prostate Exam**
men 50 and over
yearly
**Recommendations vary by provider and patient preference. Discuss with your provider.
***Recommendations vary by individual health and risk factors. Discuss with your provider.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical