Lawndale Christian Health Center Men's Preventive Health Maintenance Chart # For (#) see details at bottom Name DOB Provider Date
Place Label Here
TEST or Procedure
Prostate: (no consensus) DRE or PSA (1) Fecal Ocult Blood Test OR Flex-Sig +/- FOBT (QY) OR Barium Enema (3) OR Colonoscopy (3) Immunizations
Age to Start
50 yrs low risk 45 yrs high risk (1) 50 yrs 50 yrs 50 yrs early if high risk (3)
Frequency
Q 2 yrs Q 2 yrs Q 1 yr FOBT Q 5 yr FS-FOBT Q 5 yrs FS-BE Q 10 Colon (3)
Dates and (+) or (-)
Tetanus: once every 10 years after age 18 Influenza: over 65 years, Asthma, Diabetes, health care worker, Day care/Teacher Pneumovax: over 65 years, Diabetes, Asthma, Immuno-suppressed SEE IMMUNIZATION SHEET
Cholesterol (4) Diabetes (5) HIV/RPR (6) Other: Other: Other: Spiritual Assessment OTHER RISK FACTORS Smoking Alcohol Substance Abuse Obesity BMI) (7) Inactivity Multiple Sex Partners Domestic Violence Other:
25 years + till death earlier if high risk 45 yrs < 45 if high risk Over 18 or at onset of sex if high risk
Q5 yrs if low risk Q1y high risk (3) Q 3 yrs Q 1-3 yrs Yearly or PRN
Initial Visit
PRN
Teenager Teenager Teenager Teenager Teenager Teenager All ages
PRN PRN PRN PRN PRN PRN PRN
1) Prostate (See Guidelines for thorough explanation) Perform testing based on risk factor assessment and physician-patient decision High risk includes African Americans, those with family history of prostate cancer. Insufficient evidence to show that high risk group should be treated differently. PSA cutoff should be 2.5. If first is abnormal, repeat 2-4 weeks. If second abnormal or initial DRE abnormal, send for further work-up. PSA should be done at least 48 hours after ejaculation or local trauma (i.e. bicycle riding). 3) Colon Screening (See Guidelines for thorough explanation) Begin sooner and do more often if: Inflammatory bowel disease, personal or family history of polyps or cancer, familial syndromes like FAP or HNPCC. Continue until patient life expectancy less than 10 years or risk outweighs benefit. Cook County requires CBC, PT, and PTT within 2 weeks D-C Barium Enema = double contrast barium enemas 4) Hypercholesterolemia: high risk groups Smoker, hypertension, h/o low HDL, FHx of premature CHD, men over 45 yrs, women over 55 yrs, CHD, PVD, Carotid dz with sxs, AAA, FHx of hypercholesterolemia See ATP III for more details 5) Diabetes High risk: gestational DM, family history, obesity (BMI over 27), Race (African-Americans, Hispanics, Native Americans, Asians, pacific Islanders), Impaired Fasting Glucose history, hypertension, HD 6) STD Testing High Risk: h/o other STD, mulitple partners, high risk behaviors 7) Obesity (BMI) BMI over 30 is obese BMI 25 – 30 is overweight Revised 12/11/05
Lawndale Christian Health Center Women's Preventive Health Maintenance Chart # For (#) see details at bottom Name DOB Provider Date
Place Label Here
TEST or Procedure
Clinical Breast Exam
Age to Start
20-40 40+
Frequency
Q 3 yrs Q 1 yr
Dates and (+) or (-)
Breast Self Exam Mammogram (1)
20 y No proven ben. 40 yrs until life exp < 3-5 yrs 30 yrs if high risk
Yearly education optional Q 1 yr
Pelvic Exam, Pap, (2)
Within 3 yrs after first sex or at 21 yrs (2)
q 1-3 yrs depending on age, pap method, results(2) yearly Q 1 yr FOBT Q 5 yr FS-FOBT Q 5 yrs FS-BE Q 10 Colon (3) SEE IMMUNIZATION SHEET
Genprobe Fecal Ocult Blood Test OR Flex-Sig +/- FOBT (QY) OR Barium Enema OR Colonoscopy (3) Immunizations
Coitarche 50 yrs 50 yrs 50 yrs early if high risk (3)
Tetanus: once every 10 years after age 18 Influenza: over 65 years, Asthma, Diabetes, health care worker, Day Care/Teacher Pneumovax: over 65 years, asthma, diabetes, immuno-suppressed
Cholesterol (4) Diabetes (5) HIV/RPR (6) Other (9) Spiritual Assessment Osteoporosis Prevention (8) OTHER RISK FACTORS Smoking Alcohol Substance Abuse Obesity BMI) (7) Inactivity Multiple Sex Partners Domestic Violence Other:
20 years + till death 45 yrs < 45 if high risk Over 18 or at onset of sex
Q5 yrs if low risk Q1y high risk (4) Q 3 yrs Q 1-3 yrs Yearly
Initial Visit Menopause (bio or surgical)
PRN PRN
Teenager Teenager Teenager Teenager Teenager Teenager All ages
PRN PRN PRN PRN PRN PRN PRN
1) Breast Mammograms (See Guidelines for thorough explanation) Determination of risk by Claus statistical model and the Gail model at http://bcra.nci.hih.gov/brc/ Also high risk if prior chest irradiation, personal history of breast cancer, family history of disease associated with hereditary breast cancer such as Li-Fraumeni or Cowdens syndromes 2) Cervical Cancer Screening by Pap and Pelvic exam (See Guidelines for thorough explanation) age < 30, yrly conventional or q 2 yrs Liquid prep w reflex HPV testing on ASCUS Pap ASCUS/ HPV NEG repeat in 1 yr. PAP ASCUS/HPV POS --colposcopy Pap Normal/ HPV POS repeat pap smear in 6-12 months PAP Normal/HPV Neg, repeat 3 yrs. Pap Smear Atypical Glandular Cells (AGC) , LGSIL or Above- Colpo Age > 30, yrly conventional, q 2 yrs Liquid prep reflexHPV, Dual Screening Pap with HPV also Optional Women with cervix present after subtotal hysterectomy should be screened as other women in chart Women with no cervix present (total hysterectomy for benign reasons) can discontinue routine Paps
Women with no cervix present but hysterectomy was for CIN 2 or 3 should be screened annually until 3 consecutive,negative vaginal cytology tests Women over 65: if adequate recent screening (every 1 to 3 years) with normal Paps and are who are otherwise at low risk, routine screening is not needed. See guidelines for further deta 3) Colon Screening (See opposite side) (See Guidelines for thorough explanation) 4) Hypercholesterolemia: high risk groups (See opposite side) 5) Diabetes (See opposite side) 6) STD Testing (See opposite side) 7) Obesity (BMI) (See opposite side) 8) Osteoporosis Discuss bone loss, exercise, calcium intake and supplementation 9) Thyroid Disease No consensus or screening recommendations TSH if asymptomatic, include Free T4 is symptomatic Revised 1/11/07