Health Maintenance Flowsheet

This flowsheet applies to periodic health evaluations of asymptomatic, non-pregnant patients. Recommendations should be adapted for patients at high risk. Note that this list is not comprehensive.

Information About You:


E-mail Address: 
First Name:     
Last Name:      

Date of Birth:  

                            MM/DD/YY

AGE

25-64

65+

Date Last Done

Cholesterol

Men: Begin at 35
Women: Begin at 45
Frequency, once every 5 years.

At Clinical Discretion

Blood Pressure

Every 1-2 Years

Digital Rectal Exam

Every Year

Fecal Occult Blood

Every Year

Sigmoidoscopy or Colonoscopy

50+: Every 3-5 Years

Every 3-5 Years

Glaucoma Test

High Risk Frequency: At Clinical Discretion

Tetanus/Diptheria

Frequency: Every 10+ Years

TB Skin Test (If positive, do not repeat)

Hepatitis B Series

Once for all young adults and high risk persons.

Influenza Vaccine

High Risk: Every Year

Every Year

Pneumococcus Vaccine

High Risk: Once

Once.

Measles-Mumps-Rubella Vaccine

Once for all persons born after 1956 who lack evidence of immunity.

Counsel re Diet, Activity, Tobacco, Alcohol, Drug and Sexual Practices

Frequency: At Clinical Discretion

Advance Directives

Useful in case of any severe illness or injury, temporary or permanent

FEMALES

Breast Self-Exam (BSE)

Monthly

Clinical Breast Exam

Every Year

Mammogram

40: Baseline

40-49: Every 1-2 Years

50+: Every Year

Pelvic Exam and Pap Smear

19-39: Every 1-3 Years

40-64: Every Year

Endometrial Tissue Exam

High Risk: Once at menopause

MALES

PSA

50+: Every Year

Copyright 1996, Florida Early Diagnosis Steering Committee and Florida Academy of Family Physicians. Cancer-related procedures based on American Cancer Society recommendations. All other recommendations based on US Preventive Services Task Force, 1996. Used with permission.

AGE	25-64	65+	Date Last Done
Cholesterol	Men: Begin at 35 Women: Begin at 45 Frequency, once every 5 years.	At Clinical Discretion
Blood Pressure	Every 1-2 Years
Digital Rectal Exam	Every Year
Fecal Occult Blood	Every Year
Sigmoidoscopy or Colonoscopy	50+: Every 3-5 Years	Every 3-5 Years
Glaucoma Test	High Risk Frequency: At Clinical Discretion
Tetanus/Diptheria	Frequency: Every 10+ Years
TB Skin Test (If positive, do not repeat)	Hepatitis B Series	Once for all young adults and high risk persons.
Influenza Vaccine	High Risk: Every Year	Every Year
Pneumococcus Vaccine	High Risk: Once	Once.
Measles-Mumps-Rubella Vaccine	Once for all persons born after 1956 who lack evidence of immunity.
Counsel re Diet, Activity, Tobacco, Alcohol, Drug and Sexual Practices	Frequency: At Clinical Discretion
Advance Directives	Useful in case of any severe illness or injury, temporary or permanent
FEMALES
Breast Self-Exam (BSE)	Monthly
Clinical Breast Exam	Every Year
Mammogram	40: Baseline 40-49: Every 1-2 Years 50+: Every Year
Pelvic Exam and Pap Smear	19-39: Every 1-3 Years 40-64: Every Year
Endometrial Tissue Exam	High Risk: Once at menopause
MALES
PSA	50+: Every Year