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As a young woman between the ages of 11 - 24 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 if several people in your family have had heart attacks. Your last cholesterol was _________ (date) and it was __________.

You should have a Pap test and a test for a common infection known as chlamydia once a year if you have ever had sexual intercourse. Your last test was ____________ (date) by Dr. ____________ and it was normal / abnormal.

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

If it is possible for you to become pregnant, you should be vaccinated for the German measles and you should take vitamins every day. Are your shots up to date? YES NO Do you take a vitamin with folic acid daily?     YES     NO

You should get a tetanus booster every ten years. You should get one after the age of 15. Do you need yours today?    YES    NO

There is a chance you may not have been immunized against some preventable diseases. These include Hepatitis B, rubella, and chicken pox. Have you been? YES     NO    Not sure

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:

Smoking        Drinking           Lack of exercise       Seatbelt use               Motorcycle safety

Firearm safety         Smoke detector           Unsafe sex                   Unintended pregnancy

Dental health           Diet and exercise             Calcium intake           Depression

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