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Improve Your Health - Page 3

This checklist contains a list of common health questions. Fill out the form and click the "Finish" button at the bottom of the page. Take this checklist to your next health care appointment. During your appointment, use the checklist to ask your provider to help you:

  • Review all of the questions on the checklist.
  • Review the goals you have set for yourself to improve your health.
  • Ask for a copy of a Patient Wellness Handout and have your provider review it with you. The Patient Wellness Handout is a document available at your health care facility that provides useful information about your health.
  • Discuss any health conditions you have had.


Do I need a flu shot?
(Be sure to tell your provider if you got a flu shot somewhere else, like the local Wal-Mart.)

Do I need a pneumonia shot?
(Be sure to tell your provider if you got a pneumonia shot somewhere else, like the local Wal-Mart.)

Does my newborn child need any shots? Do you have a vaccination schedule?
(Be sure to tell your provider if your child has received vaccinations somewhere else, like the hospital.)

Medicines I currently take

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Could these cause problems with my other medicines?

Allergies to medicines

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Could that present a problem?

Breast Cancer Screening (Mammogram)

Talk with your provider about when to begin your regular mammography screening. Most organizations recommend that women begin their mammography screening at age 40.

What is a mammogram? Will the mammogram hurt?

Do I have to have a mammogram every year?

What are the benefits of beginning my mammogram screening at age 40?

What can affect my mammogram? How long will it take to get my results?

Can I perform a self examination? How accurate is it?

Cervical Cancer Screening (Pap Smear)

Women that are age 21-64 should have a Pap Smear at least every two years. Ask your provider what is best for you.

What is a Pap Test (Smear)? Will I always need to have regular pap tests?

I have had a hysterectomy. Do I still need to have a PAP?

What can affect my pap test? How long will it take to get my results?

How can I reduce my chances of getting cervical cancer?

Colorectal Cancer Screening

Colorectal cancer screening is recommended for average-risk men and women beginning at age 50. The following test(s) are recommended by the United States Preventive Services Task Force: Colonoscopy (once every 10 years), take home Fecal Occult Blood Test or Fecal Immunochemical Test (once a year) and Flexible Sigmoidoscopy (once every 5 years).

Will any of these tests be uncomfortable or painful? How long will it take to get my results?

What screening tests do you recommend for me? Why?

My family has a history of colorectal cancer; do I have a higher risk for colorectal cancer?

What happens next if I have a positive colorectal cancer screening test? Will I need a colonoscopy?

If I choose to do the screening with FOBT or FIT, why does the test need to be done at home and not while at the clinic?

Family History

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Could this affect my health? How often should I be screened for these?

Tests or shots in other facilities

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         days a week.

         minutes. Is this enough?

Alcohol and Other Substances

A drink is one bottle of beer, one glass of wine, one wine cooler, or one shot of hard liquor (like whiskey, scotch, gin or vodka).     

Is there something I can do to help me drink less?


Is there someone I can talk to for help about my drug use?









Is counseling available to help me with this? Do I need counseling?

My Health Goals

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