As a man between the ages of 25 – 64 these are some of the things we recommend that you do to stay healthy:

You should have your blood pressure and weight taken about every 2 years. Today’s blood pressure is _________ and your weight is ________.

You should have your cholesterol (a type of fat in your blood that causes heart disease) tested at least once and repeated regularly if it was abnormal or if several people in your family have had heart attacks. Your last cholesterol was _________ (date) and it was __________.

 You should have your stool tested for blood annually after age 50 and that you have a special test called a sigmoidoscopy, which looks in part of your colon. These tests help to detect colon cancer. Your last test for blood in your stool was _________ (date) and your sigmoidoscopy was _________.

If you are over 40, you should discuss with your doctor prostate cancer and whether or not the blood test for prostate cancer is right for you. Would you like to discuss this test today?    YES    NO

You should either not drink alcohol at all or drink in moderation if you are over 21. How many alcoholic beverages (beer, wine, or hard liquor) do you drink in one day? ______ Would you like to discuss this with the doctor?     YES     NO    Not sure

You should get a tetanus booster every ten years. Do you need yours today?     YES    NO

In the last year, have you been hit, kicked, slapped, or otherwise physically hurt by someone, or has anyone forced you to commit or have an unwanted sexual act?     Yes    No

You should talk to us about unhealthy habits so that we might be able to help you to reduce your risk of disease. Please circle the health habits you are concerned about:


Please call 434-3475 and ask for either your doctor or the nurse if you have any questions that we neglected to answer during your visit