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 > 40 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.
Current as of January 2003