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Preventive ServiceFrequency Last Done Body Mass Index (BMI)____
Height _______ Weight _______ AnnuallyBlood Pressure _______/_______
Every 2 yrs, if BP 120-139/80-89 mm hgVision
Every 3 yrs up to age 40;
Every 2 yrs aged 40+Breast Cancer Screening (Mammogram)Every 2 yrs, aged 50-74 yrsCervical Cancer Screening (Pap Smear)Every 3 yrs, aged 21-64 yrs;
Every 5 yrs, aged 30-65 with HPV testingOsteoporosis Screening (Bone Density Measurement)Routinely, for women aged 65+
Routinely, for women aged 60-64 with risk factorsCholesterol TestingRegularly beginning at age 20 with risk factorsDiabetes ScreeningWith a sustained BP >/= 135/80 mm HgColorectal Cancer ScreeningAnnually, Fecal Occult Blood Stool (FOBS);
Every 5 yrs, Sigmoidoscopy with FOBS;
Every 10 yrs, ColonoscopySexually Transmitted Diseases (STDs)As necessary for those with risk factorsDepression ScreeningAs necessary for those with risk factorsAlcohol Misuse ScreeningAs necessary for those with risk factorsImmunizations:
Pneumococcal (Pneumonia) Vaccine
Influenza (Flu) VaccinePneumonia: 1-2 doses up to age 64;
Pneumonia: 1 dose age 65+
Influenza: Annually
Other
Your major risk factors:
Family history of ____________________ Obesity_______ Diabetes_______ Hypertension______ Fall Risk______ Smoking Use______ Other___________
Recommendations for improvement:
Diet_____ Tobacco Cessation_____ Weight Management____ Exercise____ Other_____
Referrals
WOMENS PREVENTIVE WELLNESS PLAN
[
Patient Name______________________________ Date______________________________
atient Name
For Staff Use: [list handouts, referrals, or other followup instructions here]
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