ORCHARD MEDICAL CENTER WOMEN’S PREVENTIVE WELLNESS PLAN

Patient Name

Date of Birth

Date

Preventive Service

Dental Exam

When was your last one?

Where?

EKG

When was your last one?

Where?

Vision Screening:
(Dilated eye exam, if diabetic)

When was your last one?

Where?

Diabetic Foot Exam

When was your last one?

Where?

Breast Cancer Screening:
(Mammogram)

When was your last one?

Where?

Self-Breast Exam:

When was your last one?

Where?

Cervical Cancer Screening (Pap Smear):

When was your last one?

Where?

Osteoporosis Screening (Bone Density Measurement):

When was your last one?

Where?

Cholesterol Testing

When was your last one?

Where?

Colorectal Cancer Screening
Colonoscopy or Fecal Occult Blood

When was your last one?

Where?

Testing for Sexually Transmitted
Diseases (STD’s)

When was your last one?

Where?

Preventative Tests

When was your last one?

Where?

Immunizations:

Pneumococcal (Pneumonia)

When was your last one?

Where?

Influenza (Flu) Vaccine

When was your last one?

Where?

Diptheria, Tetanus and Pertussis

When was your last one?

Where?

Shingles (Zoster)

When was your last one?

Where?

PATIENT OCCUPATION

Please describe any change in your:

Family history

Weight

Blood Sugar

Blood Pressure

Hospitalization and Other Illnesses

Other

I would like educational materials on the following (Please check all that apply):

Diet

Tobacco Cessation

Weight Management

Exercise

Other

Please list the names of all your Doctors, Pharmacies, & Medical Equipment Suppliers or attach a current list:

Name & Specialty

Address and phone number

Add new row

Please list all your medications or attach a current list, including over-the counter medications and supplements:

Name of medicine

Strength and how many times a day

Add new row

FUNCTIONAL ABILITY/SAFETY SCREEN

Do you need help from others to perform everyday activities such as eating, getting dressed, grooming, bathing, walking or using the toilet?

Yes No

Do you need help with the phone, transportation, shopping, preparing meals, house work, laundry, medications or managing money?

Yes No

Does your home have rugs in the hallway, lack grab bars in the bathroom, lack handrails on the stairs or have poor lighting?

Yes No

Have you noticed any hearing difficulties?

Yes No

Do you feel safe at home?

Yes No

Do you have an advance directive or durable power of attorney?(If you have one, please bring a copy of it with you)

Yes No

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