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Current Concerns
Name:
Sex:
DOB: Age:
Health Card:
Tel:
Address:
Date:
Lifestyle/Habits
Diet:
Fat/Cholesterol
Fiber
Calcium
Sodium
Smoking:
Exercise:
Sexual History:
Alcohol:
Drugs:
Work/Education:
Income Below Poverty Line:
c Yes c No
Family:
Family Planning/
Contraception:
Sleep:
Relationships:
c Medications
c Hospitalizations/Surgeries
c Allergies
Functional Inquiry
Normal
Normal
Remarks
HEENT:
CVS:
Sexual
Function: c
MSK:
Resp:
Neuro:
Breasts: c
Derm:
GI:
Mental
Health:
GU/
Menses: c
Education/
Counseling
c Yes c No
Smoking c Yes c No
c smoking cessation
c nicotine replacement therapy/other drugs
c dietary advice on fruits and green leafy vegetables
c referral to validated smoking cessation program
Constitutional SX: c
Behavioural
Remarks
Alcohol
Personal Safety
drinking
c counseling for problem drinking
c hearing protection
c noise control programs
c seat belts
c Yes c No
c case finding for problem
Elderly
c Yes c No
c cognitive assessment
(if concerns)
c fall assessment (if history of falls)
Oral Hygiene
c brushing/flossing teeth
c fluoride (toothpaste/
Parents with
children
c Yes c No
c poison control
prevention
c smoke detectors
c non-flammable
sleepwear
settings (<54C)
supplement)
c tooth scaling and prophylaxis
c smoking cessation
Endorsed by:
Please note:
Bold
= Good evidence (from the Canadian Task Force on Preventive Health Care)
Italics = Fair evidence (from the Canadian Task Force on Preventive Health Care)
Plain text = Guidelines (from other Canadian sources)
Name:
Physical Examination
BP:
HR:
RR:
HT:
WT:
BMI:
Eyes:
Snellen sight card:
R
L
Nose:
Ears:
Mouth/Throat:
Waist Circumference:
Ratio:
Hip Circumference:
Breasts:
Abdo:
Ano-Rectum:
Pelvic: c Pap
Neuro:
Neck/ Thyroid:
Derm:
CVS:
MSK/Joints:
Resp:
Extremities:
Labs/Investigations
Age
21-64 years
c Mammography (50-69 yrs, q1-2)
c Hemoccult multiphase q1-2 years (age 50)
OR c Sigmoidoscopy
OR c Colonoscopy
c Cervical Cytology q1-3 yrs (sexually active until age 69)
c Gonorrhea/Chlamydia/Syphilis/HIV/HBV screen (high risk)
c Fasting Lipid Profile (50 yr or postmenopausal or sooner if at risk)
c Fasting Blood Glucose, at least q3 yrs (40 yr or sooner if at risk)
c Bone Mineral Density if at risk (reassess risk in 1-3 yr if moderate
Immunizations
65 years
c Mammography (50-69 yrs, q1-2)
c Hemoccult Multiphase q1-2 years (age 65-74)
OR c Sigmoidoscopy
OR c Colonoscopy
c Audioscope (or inquire/whispered voice test)
c Fasting Lipid Profile
c Fasting Blood Glucose, at least q3 yrs (more often if at risk)
c Bone Mineral Density (reassess risk in 1-3 yr if moderate risk, in 5 yr if low risk)
c Varicella Immunity
Date: Signature:
References: See explanation sheet for references and recommendations.
Endorsed by: