Significant Past Medical History:

Screening Dates

Last Physical:

Women’s health
-Pap Smear (≥ 21 yrs):
-Mammogram (≥ 40 yrs):
-DEXA Scan (≥ 65 yrs):

Men’s Health
-Abdominal U/S (AAA Screen – 65-75 yr who have ever smoked):
-PSA:

Colon cancer screening
-Colonoscopy (≥ 50 yrs):
-Stool Guaiac (≥ 50 ):

Diabetes patients
-Ophthalmology Evaluation:
-Monofilament:
-HbA1c:

Lipid Screen:
Pneumonia Vaccine :
Flu Vaccine (everyone):
Tetanus (every 10 yrs):

EKG:
CXR:
Hepatitis Screen:
STD Screen:
TB Screen:

Vision Screen:
Hearing Screen :
Optometry:
Dental:

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