You should have your blood pressure and weight taken about every 2 years. Todays 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