American College of Physicians | Internal Medicine | ACP



Name: _____________________________________

DOB: ______________________________________

Medical Record #: ____________________________

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Adult Health Maintenance

|Problems Evaluated & Test Results |Consultants & Specialists |

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( See Previous Adult Health Maintenance Sheet

|Health Maintenance |

|(Enter date of procedure/exam) Women |

|Breast Exam | | | | | | | |

|Mammogram | | | | | | | |

|Breast Self Exam Education | | | | | | | |

|PAP | | | | | | | |

|Men |

|Testicular Self Exam Education | | | | | | | |

|DRE | | | | | | | |

|PSA | | | | | | | |

|Geriatric |

|Mini-Mental Status Exam | | | | | | | |

|Functional Assessment | | | | | | | |

|Advance Directives | | | | | | | |

|General |

|Flex Sig/Colon | | | | | | | |

|Stool for Occult Blood | | | | | | | |

|Dental Exam | | | | | | | |

|Dilated Eye Exam | | | | | | | |

|Diabetic Foot Exam | | | | | | | |

|Monofilament Exam | | | | | | | |

|ECG | | | | | | | |

|High Risk Screening Tool | | | | | | | |

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