ORCHARD MEDICAL CENTER MEN’S PREVENTIVE WELLNESS PLAN

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Preventive Service

Dental Exam

EKG

Vision Screening: (Dilated eye exam, if diabetic)

Diabetic Foot Exam

Abdominal Aortic Anuerysm (Abdominal Ultrasound)

PSA (Prostate-Specific Antigen)

Cholesterol Testing

Colorectal Cancer Screening Colonoscopy or Fecal Occult Blood

Digital Rectal Exam

Testing for Sexually Transmitted Diseases (STD’s)

Immunizations:

Pneumococcal (Pneumonia)

Influenza (Flu) Vaccine

Diptheria, Tetanus and Pertussis

Shingles (Zoster)

Preventative Tests

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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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