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Health Maintenance
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Does patient have a history of...? (select only if so)
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No known history of abnormal lipids?
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Lipid screen status (indicate date last ordered or normal)
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No known history of diabetes, prediabetes, or hyperglycemia?
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Diabetes screen status (indicate date A1c or blood sugar last ordered or normal)
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No known history of HCV infection?
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HCV screen status (indicate date last ordered or normal)
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No known history of HIV infection?
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HIV screen status (indicate date last ordered or normal)
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Influenza vaccination status (indicate season last received or discussed)
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Tetanus vaccination status (indicate/estimate year last received or discussed)
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Aged >65, or other indication for PPSV23/PCV13?
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Pneumovax status (indicate/estimate year last received or discussed)
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Prevnar status (indicate/estimate year last received or discussed)
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Aged >50?
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Shingrix status (indicate/estimate year(s) received or last discussed)
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Miscellaneous Vaccination Notes
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Personal history of colorectal cancer?
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Family history of colorectal cancer?
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Aged <80?
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Date of last colorectal cancer screen (indicate/estimate year and method; indicate "never" if appropriate)
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Date of next recommended colorectal cancer screen (or when it was last recommended)
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Male?
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Personal history of prostate cancer?
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Family history of prostate cancer?
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Desire prostate cancer screen?
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PSA ordered?
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PSA status
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Ever smoked?
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Aged 65-75?
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AAA screen status
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Smoked 30 pack-years?
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Personal history of lung nodules?
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Personal history of lung cancer?
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Lung cancer screen status
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Female?
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Personal history of breast cancer?
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Family history of breast cancer?
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Aged >40?
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Breast cancer screen status
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Personal history of abnormal bone density?
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Aged >65?
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Bone density screen status (if no prior T-score less than 1)
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Aged 21-65?
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Personal history of cervicectomy (or total hysterectomy)?
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Cervical cancer screen status (if retains cervix)
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At risk for STIs (multiple sexual partners)?
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GC screen status
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Aged 50-80?
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Ever smoked?
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Smoked 30 pack-years?
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Personal history of lung nodules?
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Personal history of lung cancer?
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Lung cancer screen status
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Miscellaneous Notes (such as screening indicated outside of customary age ranges)
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