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 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 a Pap test once a year unless you have had several normal tests in a row and have never had an abnormal test. Your last test was ____________ (date) by Dr. ____________ and it was normal / abnormal.
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 _________.
You should be tested annually after age 50 (or sooner if your mother or sister had breast cancer) with a special x-ray called a mammogram and that you have a breast exam done every year by a physician. We also recommend that you examine yourself every month. Your last mammogram was _________ (date) 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. 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:
Smoking Drinking and driving Menopause Lack of exercise
Seatbelt use Motorcycle safety Firearm safety Smoke detector Depression
Unsafe sex Osteoporosis Unintended pregnancy Dental health Diet
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