Adult Health Maintenance
Age: years old
Gender:
HISTORY:
Presents for a health maintenance check-up
Last check-up was ago
Current symptoms:
Medications:
Adherence: ,
Over-the-counter supplements: , ,
Past medical history:
Family history: , , , , , ,
Social history:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
Diet: , , , ,
Physical activity:
Weight: ,
Occupation:
Labs:
Creatinine:
Na: , K:
Hb:
HbA1c:
Lipids: , Cholesterol: , LDL: , HDL: , Triglycerides:
TSH:
PSA:
Urinalysis:
Screenings:
Dyslipidemia:
Diabetes:
Colon cancer:
Prostate cancer:
Breast cancer:
Cervical cancer:
STIs:
Osteoporosis:
Depression:
Vaccinations:
Pneumococcal:
Influenza:
Covid:
Zoster:
Tdap:
HPV:
Hepatitis A:
Hepatitis B:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Metrics: weight: , height: cm, waist: cm, BMI:
Head: , scalp
Eyes: conjunctiva/sclera , lids/lashes , cornea , , extraocular movements , OD 20/, OS 20/
Ears: tympanic membranes , auditory canal on , hearing
Nose: , discharge ,
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Breasts: , ,
Abdomen: , , ,
Anorectal: DRE , prostate , , , anus
Genital: penis , testes and epididymis ,
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought , , judgment
ASSESSMENT:
PLAN:
Investigations:
- Colonoscopy
- FIT test
- Pap smear
- Mammogram
- Blood work: , , , , , , , , ,
- Bone density test
Treatments:
- Vaccinations: annual , if aged ≥ 65 or conditions, if aged 50 and older, every 10 years,
- Dietary counseling: balanced diet rich in fruits, vegetables, lean proteins, and whole grains
- Exercise counseling: at least 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic activity per week, plus muscle-strengthening activities twice per week
- Smoking cessation counseling
- Alcohol moderation counseling
- Weight management counseling
Further care:
- Follow-up in
- Return if new symptoms develop or condition worsen
HISTORY: EXAM: ASSESSMENT: PLAN: