ORCHARD MEDICAL CENTER WOMEN’S PREVENTIVE WELLNESS PLAN

Please correct the errors described below.

Preventive Service

Dental Exam

EKG

Vision Screening: (Dilated eye exam, if diabetic)

Diabetic Foot Exam

Breast Cancer Screening: (Mammogram)

Self-Breast Exam:

Cervical Cancer Screening (Pap Smear):

Osteoporosis Screening (Bone Density Measurement):

Cholesterol Testing

Colorectal Cancer Screening Colonoscopy or Fecal Occult Blood

Testing for Sexually Transmitted Diseases (STD’s)

Preventative Tests

Immunizations:

Pneumococcal (Pneumonia)

Influenza (Flu) Vaccine

Diptheria, Tetanus and Pertussis

Shingles (Zoster)

Please describe any change in your:

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

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

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FUNCTIONAL ABILITY/SAFETY SCREEN

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