Name:_________________________
Date of Birth/Age:_______________
Male:___
Female:___
MR# or SS#:___________________
Ethnicity:______________________
Medications:___________________
Old Records:___________________
Allergies:______________________
Smoker:_____
ETS:________________
Date:_______________
Screening: 1. Vaccine-preventable diseases
Annual Assessment of Risk Factors—Needs the following immunizations:
____Td booster— > 10 yr since last booster
Date of last Td_______
____Hepatitis B—at increased risk
____Varicella—nonimmune adults
____Rubella—nonimmune females of childbearing age and health care workers
without evidence of immunity or prior immunization
____Hepatitis A—at high risk
____Influenza— > 50 yr or high risk
____Pneumococcal— > 65 yr or high risk
Counseling Provided:
Screening: 2. Blood pressure (BP)
Annual Assessment of Risk Factors:
____Weight
____BP
____Does not exercise 30 minutes most days of week
____First-degree family history of high blood pressure or personal
history of hypertension
____Diabetes mellitus
Counseling Provided:
Screening: 3. Height/weight
Annual Assessment of Risk Factors:
____Above healthy weight range for height OR
____BMI > 25. Formula for calculating BMI is Weight (kg) / Height (m)2
Counseling Provided:
Screening: 4. Cholesterol
Annual Assessment of Risk Factors:
____In males > 35 yr and females > 45 yr
____>1 yr since previous abnormal test
____Diabetes mellitus
____Family history of cardiovascular disease < 50 yr in male relatives,
< 60 yr in female relatives
____Family history suggestive of familial hyperlipidemia
____Multiple coronary heart disease risk factors (e.g., tobacco use, hypertension)
Counseling Provided:
Screening: 5. Diabetes
Annual Assessment of Risk Factors:
____Adults with hypertension or hyperlipidemia
Counseling Provided:
Screening: 6. Pap smear
Annual Assessment of Risk Factors:
____Is or has been sexually active
____> 3 yr since last Pap smear
____Abnormal
____Date
Counseling Provided:
Screening: 7. Mammogram
Annual Assessment of Risk Factors:
____ > 40 yr and has not had a mammogram within the past 1-2 yr
____ Family history of breast cancer
Counseling Provided:
Screening: 8. Colorectal cancer screening
Annual Assessment of Risk Factors:
____ > 50 yr
____ Family members who have a positive history of cancer of colon,
intestine, breast, ovaries, or uterus
____ History of polyps
Counseling Provided:
Screening: 9. Osteoporesis
Annual Assessment of Risk Factors:
____Women > 65 years
____Women > 60 years at increased risk for fractures
Counseling Provided:
Screening: 10. Problem drinking
Annual Assessment of Risk Factors:
____Drinks > 2 drinks/day (men) OR > 1 drink/day (women)
Counseling Provided:
Screening: 11. Vision
Annual Assessment of Risk Factors:
____If > 65 yr, does not see an eye doctor for regular eye exams
____Glaucoma
____Diabetes mellitus
____Wears glasses
____Family history of glaucoma
Counseling Provided:
Screening: 12. Hearing
Annual Assessment of Risk Factors:
____> 65 yr strains to hear a normal conversation
____Turns up volume on TV and radio so loud that others complain
Counseling Provided:
Screening: 13. Chlamydial infection
Annual Assessment of Risk Factors:
____Is sexually active and < 25 yr
____Prior history of STD
____New or multiple sex partners
____Had cervical ectopy
____Uses barrier contraceptives inconsistently
Counseling Provided:
For Persons at High Risk: 14. STD/HIV
Annual Assessment of Risk Factors:
____Contraception
____Has or has had any one of the following risk factors:
Previous STD, multiple sex partners, or shared needles
Counseling Provided:
For Persons at High Risk: 15. Tuberculosis (TB) infection
Annual Assessment of Risk Factors:
____Close contact with a person who has active TB
____Occupational high risk (health care, correctional, residential, etc.)
____Lived in endemic area in the past year (SE Asia, Africa, Latin America)
____Medical risk factors (e.g., diabetes, HIV, alcoholism)
____PPD status
____INH
Counseling Provided:
Chemoprevention: 16. Discuss aspirin to prevent coronary heart disease
Annual Assessment of Risk Factors:
____At risk for coronary heart disease
Counseling Provided:
Chemoprevention: 17. Discuss breast cancer chemoprevention
Annual Assessment of Risk Factors:
____Women of older age
____Breast cancer in first degree relative
____Atypical hyperplasia or breast biopsy
Counseling Provided:
Counseling: 18. Tobacco use
Annual Assessment of Risk Factors:
____Currently smokes cigarettes, cigars, or pipes or uses smokeless tobacco
____Is exposed to tobacco smoke regularly
____Number of packs per day
____Carcinoma
____Coronary artery disease
Counseling Provided:
Counseling: 19. Alcohol/drug use
Annual Assessment of Risk Factors:
____Long-term use of certain prescription drugs
____Has had medical/social problems related to alcohol or drug use
____Uses or has used "street drugs"
Counseling Provided:
Counseling: 20. Nutrition
Annual Assessment of Risk Factors:
____Does not limit intake of fat and cholesterol, maintain caloric balance
in diet, or eat foods containing fiber
Counseling Provided:
Counseling: 21. Physical activity
Annual Assessment of Risk Factors:
____Does not exercise 30 minutes most days
Counseling Provided:
Counseling: 22. Oral health
Annual Assessment of Risk Factors:
____Poor dental hygiene (e.g., does not brush with a fluoride toothpaste and floss daily)
____Does not see a dentist regularly
____Smokes or chews tobacco and/or drinks alcohol
Counseling Provided:
Counseling: 23. Sun exposure
Annual Assessment of Risk Factors:
____Immunosuppression
____Family history of skin cancer
____Freckles and poor tanning ability
____Light skin, hair, and eye color
Counseling Provided:
Counseling: 24. Injury prevention
Annual Assessment of Risk Factors:
____Does not use seatbelts when in a motor vehicle
____Does not use a helmet when on a bike/motorcycle
____Drinks alcohol and drives, or rides with someone who does
____Medicines, chemicals/poisons, or firearms are accessible to children
____Does not have working smoke detectors in the home
____At risk for battering or abuse (emotional, verbal, or physical)
Counseling Provided:
Counseling: 25. STD/HIV
Annual Assessment of Risk Factors:
____Contraception
____Previous STD, multiple sex partners, or shared needles
Counseling Provided:
Counseling: 26. Unintended pregnancy
Annual Assessment of Risk Factors:
____Sexually active male or sexually active female of childbearing age
____Does not desire a pregnancy/is not using a reliable birth control method
Counseling Provided:
Counseling: 27. Multivitamin with folic acid
Annual Assessment of Risk Factors:
____Sexually active female of childbearing age
Counseling Provided:
Counseling: 28. Osteoporosis
Annual Assessment of Risk Factors:
____Does not do weight-bearing exercises
____Does not get adequate calcium
____Low body weight
____Caucasian female
____Menopause at <40 yr
Counseling Provided:
Notes/Instructions:
Completed by:
Date:
Reviewed by clinician:
Date:
Note: Information is based on U.S. Preventive Services Task Force recommendations.
ETS = environmental tobacco smoke; Td = tetanus-diphtheria; BMI = body mass index; STD = sexually transmitted disease; HIV = human immunodeficiency virus; PPD = tuberculin purified protein derivative; INH = isoniazid.
Current as of January 2003
Name:_________________________
Date of Birth/Age:_______________
Male:___
Female:___
MR# or SS#:___________________
Ethnicity:______________________
Medications:___________________
Old Records:___________________
Allergies:______________________
Smoker:_____
ETS:________________
Date:_______________
Screening: 1. Height/weight
Annual Assessment of Risk Factors:
____Above or below healthy weight range for height
Counseling Provided:
Screening: 2. Blood pressure
Annual Assessment of Risk Factors:
____Screen during office visits
Counseling Provided:
Screening: 3. Vision
Annual Assessment of Risk Factors:
____Screen at approximately 3-4 yr
____Eyes turning inward or outward
____Squinting
____Headaches
____Not doing as well in school as before
____Blurred or double vision
Counseling Provided:
Screening: 4-6. PKU, hemoglobinopathies, hypothyroidism
Annual Assessment of Risk Factors:
____Screening tests done in first 7 days after delivery
____Records from hospital should be in chart
Counseling Provided:
Screening: 7. Hearing
Annual Assessment of Risk Factors:
____Family history of hereditary childhood sensorineural hearing loss
____Congenital perinatal infection with herpes
____Perinatal infection with herpes, syphilis, rubella, cytomegalovirus, or toxoplasmosis
____Malformations involving head or neck
____Birth weight below 1500 g
____Bacterial meningitis
____Hyperbilirubinemia requiring exchange transfusion
____Severe perinatal asphyxia
____Ototoxic medications
Counseling Provided:
Screening: 8. Anemia (for those at high risk)
Annual Assessment of Risk Factors:
____Lives in poverty
____Black, Native American, or Alaska Native
____Immigrant from developing country
____Preterm and low birth weight infant
____Drinks primarily unfortified cow's milk
Counseling Provided:
Screening: 9. Cholesterol (for those at high risk)
Annual Assessment of Risk Factors:
____Has a parent who has high cholesterol
____Has a parent or grandparent who died suddenly or had heart disease before age 55
____Child is obese
____Has high blood pressure
Counseling Provided:
Screening: 10. Lead (for those at high risk)
Annual Assessment of Risk Factors:
____Lived in or regularly visited a house built before 1950
____Lived in or regularly visited a house built before 1978 with recent,
ongoing, or planned renovation or remodeling
____Had a brother or sister, housemate, or playmate followed or treated
for lead poisoning
____Is anemic
Counseling Provided:
Screening: 11. Tuberculin skin test (for those at high risk)
Annual Assessment of Risk Factors:
____Close contact with a person who has active tuberculosis
____Occupational high risk (health care, correctional, residential, etc.)
____Lived in endemic area in the past year (SE Asia, Africa, Latin America)
____Medical risk factors (e.g., diabetes, HIV, alcoholism)
Counseling Provided:
Screening: 12. HIV test (for those at high risk)
Annual Assessment of Risk Factors:
____High-risk mother and antibody status of mother is unknown
____Inconsistent and incorrect use of barrier contraceptives
____Has or has had any one of the following risk factors:
previous STD, multiple sex partners, or shared needles
Counseling Provided:
Screening: 13. Chlamydia
Annual Assessment of Risk Factors:
____Is sexually active and > 25 yr
Counseling Provided:
Screening: 14. Pap smear
Annual Assessment of Risk Factors:
____Is sexually active and has been over 3 yr since last test
Counseling Provided:
Counseling: 15. Sleep position
Annual Assessment of Risk Factors:
____Places baby on stomach
Counseling Provided:
Counseling: 16. Injury prevention
Annual Assessment of Risk Factors:
____Does not use child safety car seats/booster seats
____Does not use lap/shoulder belts
____Does not use a bicycle helmet
____Does not have hot-water heater temperature < 120-130°F
____Medicines, chemicals/poisons, or firearms are accessible to children
____Does not have window/stair guards or a pool fence
____Does not have syrup of ipecac or the poison control phone number
____Does not have working smoke detectors in the home
Counseling Provided:
Counseling: 17. Nutrition
Annual Assessment of Risk Factors:
____Mother does not breast-feed
____Does not limit intake of fat and cholesterol, maintain calorie
balance in diet, or eat foods containing fiber
____Inadequate calcium intake for teen girls
Counseling Provided:
Counseling: 18. Physical activity
Annual Assessment of Risk Factors:
____Does not get 30 minutes of physical activity most days
Counseling Provided:
Counseling: 19. Oral health
Annual Assessment of Risk Factors:
____Poor dental hygiene (e.g., does not brush with a fluoride toothpaste and floss daily)
____Does not see a dentist regularly
____Smokes or chews tobacco and/or drinks alcohol
Counseling Provided:
Counseling: 20. Sun exposure
Annual Assessment of Risk Factors:
____Immunosuppression
____Family history of skin cancer
____Freckles and poor tanning ability
____Light skin, hair, and eye color
Counseling Provided:
Counseling: 21. Tobacco use
Annual Assessment of Risk Factors:
____Currently smokes cigarettes, cigars, or pipes or uses smokeless tobacco
____Lives with an adult who smokes inside the home
Counseling Provided:
Counseling: 22. Alcohol/drug use
Annual Assessment of Risk Factors:
____Drinks more than 2 drinks/day (men) or 1 drink/ day (women)
(quantity______________ frequency____________)
____Uses or has used "street drugs"
____Has had medical and/ or social problems related to alcohol or drug use
Counseling Provided:
Counseling: 23. Unintended pregnancy/STDs/HIV
Annual Assessment of Risk Factors:
____Sexually active male or sexually active female of childbearing age
____Does not desire a pregnancy/is not using a reliable birth control method
Has or has had previous STD, multiple sex partners, or shared needles
Counseling Provided:
Counseling: 24. Multivitamin with folic acid
Annual Assessment of Risk Factors:
____Sexually active female of childbearing age
Counseling Provided:
Notes/Instructions:
Completed by:
Date:
Reviewed by clinician:
Date:
Note: Information is based on U.S. Preventive Services Task Force recommendations.
ETS = environmental tobacco smoke; Td = tetanus-diphtheria; BMI = body mass index; STD = sexually transmitted disease; HIV = human immunodeficiency virus; PPD = tuberculin purified protein derivative; INH = isoniazid.
Name:_________________________
Date of Birth/Age:_______________
Male:___
Female:___
MR# or SS#:___________________
Ethnicity:______________________
Medications:___________________
Old Records:___________________
Allergies:______________________
Smoker:_____
ETS:________________
Date:_______________
1. Immunizations
Tetanus—diphtheria
Population/Frequency: q 10 yr
I. D.:___________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Hepatitis B
Population/Frequency: Adults at increased risk—3-dose series
I. D.:___________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Varicella
Population/Frequency: Nonimmune adults
2 doses delivered 4-8 wk apart
I. D.:___________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Rubella
Population/Frequency: Women of childbearing age and health care workers without evidence of immunity or prior
immunization—1 dose
I. D.:___________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Hepatitis A
Population/Frequency: At high risk
I. D.:___________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Influenza vaccine
Population/Frequency: q 1 yr > 50 yr or at increased risk
I. D.:___________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Pneumococcal vaccine
Population/Frequency: Once > 65 yr or at increased risk
I. D.:___________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Date/ Site/ Sig.:______________________________________
Screening Test/Exam
2. Blood pressure
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
3. Height/weight
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
4. Total cholesterol, HDL
Population/Frequency: > 35 yr males; > 45 yr females
Date: _______________________
Age: _______________________
Results*: ____________________
5. Diabetes
Population/Frequency: Periodically, adults with hypertension or hyperlipidemia
Date: _______________________
Age: _______________________
Results*: ____________________
6. Pap smear
Population/Frequency: q 3 yr
Date: _______________________
Age: _______________________
Results*: ____________________
7. Mammogram
Population/Frequency: q 1-2 yr > 50 yr
Date: _______________________
Age: _______________________
Results*: ____________________
8. Colorectal cancer screeninga
Population/Frequency: Depends on screening test selected
Date: _______________________
Age: _______________________
Results*: ____________________
9. Osteoporosis
Population/Frequency: Routinely for women > 65 or women > 60 with increased risk for fractures
Date: _______________________
Age: _______________________
Results*: ____________________
10. Problem drinking
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
11. Vision
Population/Frequency: > 65 yr
Date: _______________________
Age: _______________________
Results*: ____________________
12. Hearing
Population/Frequency: > 65 yr
Date: _______________________
Age: _______________________
Results*: ____________________
13. Chlamydial infection
Population/Frequency: Sexually active women age < 25
Date: _______________________
Age: _______________________
Results*: ____________________
High Risk
14. STD/ HIV
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
15. TB infection/PPD
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
aSee USPSTF Recommendation and Rationale on colorectal cancer screening.
Chemoprevention
16. Discuss aspirin to prevent CHD
Population/Frequency: High risk
Date: _______________________
Age: _______________________
Results*: ____________________
17. Discuss breast cancer chemoprevention
Population/Frequency: Women at high risk
Date: _______________________
Age: _______________________
Results*: ____________________
Counseling
18. Tobacco use
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
19. Alcohol/drug use
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
20. Nutrition
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
21. Physical activity
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
22. Oral health
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
23. Sun exposure
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
24. Injury prevention
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
Sexuality/Reproduction
25. STD/HIV
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
26. Unintended pregnancy
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
27. Multivitamin with folic acid
Population/Frequency: Females capable of pregnancy
Date: _______________________
Age: _______________________
Results*: ____________________
28. Osteoporosis/calcium
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
Results*: ____________________
*Results Key: N, Results Normal; A, Results Abnormal; R, Refused; P, Pending.
Referrals (As indicated): Diabetes education
Date: _______________________
Result: _____________________________________________________________________
Referrals (As indicated): Nutrition education
Date: _______________________
Result: _____________________________________________________________________
Referrals (As indicated): Tobacco cessation program
Date: _______________________
Result: _____________________________________________________________________
Referrals (As indicated): Dental examination
Date: _______________________
Result: _____________________________________________________________________
Referrals (As indicated): Eye exam/ glaucoma
Date: _______________________
Result: _____________________________________________________________________
Note: Screening tests/ exams and counseling based on U. S. Preventive Services Task Force recommendations.
ETS = environmental tobacco smoke; HDL = high-density lipoprotein; STD = sexually transmitted disease; HIV = human immunodeficiency virus; TB = tuberculosis; PPD = tuberculin purified protein derivative; CHD = coronary heart disease.
Name:_________________________
Date of Birth/Age:_______________
Male:___
Female:___
MR# or SS#:___________________
Ethnicity:______________________
Medications:___________________
Old Records:___________________
Allergies:______________________
Smoker:_____
ETS:________________
Date:_______________
Screening Test/Exam
1. Height/ weight
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
2. Blood pressure
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
3. Vision
Population/Frequency: At 3-4 yr
Date: _______________________
Age: _______________________
4. PKU
Population/Frequency: Newborn
Date: _______________________
Age: _______________________
5. Sickle cell hemoglobinopathies
Population/Frequency: Newborn
Date: _______________________
Age: _______________________
6. Hypothyroidism
Population/Frequency: Newborn
Date: _______________________
Age: _______________________
High Risk
7. Hearing
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
8. Anemia
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
9. Cholesterol
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
10. Lead
Population/Frequency: 12 mo
Date: _______________________
Age: _______________________
11. Tuberculin skin test
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
12. HIV test
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
For Sexually Active Females
13. Chlamydia
Population/Frequency: Sexually active
Date: _______________________
Age: _______________________
14. Pap smear
Population/Frequency: Sexually active
Date: _______________________
Age: _______________________
Counseling
15. Sleep position
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
16. Injury prevention including car seat/seatbelt
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
17. Nutrition including calcium
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
18. Physical activity
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
19. Oral health including fluoride
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
20. Sun exposure
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
21. Tobacco use
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
22. Alcohol/drug use
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
23. Unintended/pregnancy/STDs/HIV
Population/Frequency: _______________________
Date: _______________________
Age: _______________________
24. Multivitamin with folic acid
Population/Frequency: Females
Date: _______________________
Age: _______________________
Referrals (As indicated): Hearing examination
Date: _______________________
Result: _____________________________________________________________________
Referrals (As indicated): Dental examination
Date: _______________________
Result: _____________________________________________________________________
Referrals (As indicated): Mental health counseling
Date: _______________________
Result: _____________________________________________________________________
Referrals (As indicated): Substance abuse counseling
Date: _______________________
Result: _____________________________________________________________________
Note: Screening tests/exams and counseling based on U. S. Preventive Services Task Force recommendations.
ETS = environmental tobacco smoke; HIV = human immunodeficiency virus; STD = sexually transmitted disease.
Use the following boxes to record each step of your current clinical flow and to identify how your clinical setting incorporates prevention activities. Specify with whom the patient meets and interacts and briefly describe the nature of the interaction. Identify when forms are completed and when services are documented.
Patient Enters the Clinic for an Appointment
Answer the following questions to help you complete the information above.
Patient Sees the Clinician
Answer the following questions to help you complete the box above.
Patient Exits the Clinic
Answer the following questions to help you complete the box above.
Current as of January 2003