Maintenance Flow Sheet - Health Partners Plans printable pdf download

2013 Adult/Well Elderly Preventive Health Guideline – Maintenance Flow Sheet

Patient Name:

DOB: __/__/__

SEX: F/M

Date of Initial Visit:

Allergies:

Habits: Smoking: ___

Alcohol: ___

Drugs: ____

CRITERIA

20__

Date of Visit:

COMPLETE HISTORY AND PHYSICAL EXAM

INTERIM HISTORY AND DIRECTED PHYSICAL EXAM

Physical Assessment (annually)

Blood Pressure Measurement

Height

Weight

Body Mass Index (BMI) calculated

Screenings

Colorectal Screening: (ages 50-80) (45 if AA, American Indian/Alaska Natives)

Fecal Occult Blood (annually) or Colonoscopy (every 10 years) or

Sigmoidoscopy (every 5 years)

Mammography (annually, starting at age 40) *

Digital Rectal Exam (DRE) (Male annually, starting at age 40)

Papanicolaou Smear (Female age 21-65 every 3 years starting age 21, over 30 include

HPV testing;over 30 interval can be extended to every 5 years by co-testing with combination

PAP and HPV testing. Annual for women at high risk) Refer to GYN

Chlamydia (all sexually active Female)

Clinical Breast Exam (every 3 years ages 20-39, and annually, starting at age 40 per ACS)

Cholesterol (every 5 years, high risk more often)

Fasting Blood Glucose (every 3 years at age 45, high risk more often)

Prostate-specific Antigen (PSA) discussion (Male starting at age 55)

Thyroid Stimulating Hormone (TSH/Thyroxine)

Depression Evaluation (annually)

Vision Screening (Snellen Chart) (annually, starting at age 65)

Test/Inquire for Hearing Impairment (annually, starting at age 65)

Oral & Dental Evaluation (annually, starting at age 65)

Mental Status Exam (annually, starting at age 65)

Osteoporosis Risk Screening(assessment and testing – Women at risk at age 65 or

younger)

Abdom. Aortic Aneurysm Screen (smokers Male ages 65-75)

Immunizations: CDC Adult Immunizaton Recommendations

Tetanus – Diphtheria Booster (replace with Tdap one time dose )(every 10 years)

Influenza Vaccine (annually)

Pneumococcal Vaccine (once at age 65 )

Measles – Mumps – Rubella Booster (adult born during/before 1957 lacking disease or

vaccination)

Varicella /Shingles vaccine (age 60 and older)

Hepatitis B (at high risk)

HPV Vaccine-age appropriate (ages 9-26)

Medications

Calcium/Vitamin D

Folate (women of childbearing age)

Aspirin – Chemoprophylaxis/Counseling (men age 45 & women age 55)

Counseling

Diet

Exercise

Depression

Safety & Injury Prevention: Seat Belt/Shoulder Belt/Appropriate Helmet Use,

Smoke Detector, Hot Water Heater, Firearms, Motor Vehicle Safety

Tobacco/Second Hand Smoking

Alcohol/Drugs

Abuse & Violence Prevention

Sexual Behavior

Protection from UV Light

Dental Health

Elder Abuse (annually, starting at age 65)

Fall Prevention (annually, starting at age 65)

OTHER

Advance Directives

ICSI guideline note: All women age 40-49 should be given the opportunity to receive information about breast cancer screening and informed decision-making therefore screening mammograms could

be recommended. Health Partners recommends mammograms starting age 40.

QM-006 08/13

Maintenance Flow Sheet - Health Partners Plans

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