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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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