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
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 CHD events
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