- for Patients
- Improve Your Health
- Improve Your Health - Page 4
Improve Your Health - Page 4
- Review all of the information in your checklist below.
- To make any changes to the information you provided in your checklist click the "Previous Page" button.
- To reset your checklist click the "Home" button.
- If you are satisfied with your checklist click the "Printable Version" button at the bottom of the page.
- Click the "Print" link near the top of the printable page.
- The Print window is displayed. Choose your printer and then click the "Print" button.
You wish to discuss Basic information.
Diabetes
What is my blood sugar (A1c) score? What can I do to get a lower score?
What is my "bad" cholesterol score? How can I get a better score?
What is my blood pressure? How can I improve it?
Why is diabetes affecting my vision? How often should I get my vision checked? What can I do to protect my vision?
If I'm overweight, how many pounds do I have to lose to make a difference in my health?
What kind of changes do I need to make to my diet?
(For women) What should I do about taking care of my diabetes if I plan to become pregnant?
Uncontrolled Blood Sugar
What is my blood sugar (A1c) score? What can I do to get a lower score?
How often and under what conditions should I test my blood sugar? What should I do with the results?
What are the warning signs or symptoms that my blood sugars are too high or too low?
High Cholesterol
I've had some form of cardiovascular disease. How can I lower my LDL cholesterol?
How often should I have my levels checked? Where should my cholesterol levels be at?
How does exercise affect my cholesterol levels?
High Blood Pressure
I've had high blood pressure. How can I lower my blood pressure?
What should my blood pressure range be?
How frequently should I have my blood pressure checked? How should I check my blood pressure?
Diabetic Nephropathy
Have my kidneys permanently and totally failed?
Will I need dialysis?
What can I do to prevent any future kidney failures?
Dental
What can I do to prevent tooth decay? How can I improve my dental health?
How often should I get fluoride treatments or sealants?
How can I prevent gum disease (periodontal disease)?
Human Papillomavirus
What is HPV and how did I get it?
How does HPV cause cervical cancer? Will I always have HPV?
How is the Pap test different from the HPV test? How often should I be tested?
What should I know about human papillomaviruses (HPV)? How will I know if I have HPV?
What can I do to reduce my risk of cervical cancer?
Prenatal HIV
I feel fine and don't think I am at risk for HIV. Why do I need to get an HIV test because I'm pregnant?
I have HIV. Can my baby get HIV? How can I find out if my baby has HIV?
Should I breastfeed my baby if I have HIV?
Heart Attack
I've had a heart attack. Do I need medicine to help prevent future heart attacks?
I've had some form of cardiovascular disease. How can I lower my LDL cholesterol?
What can I do to minimize my risk of having another heart attack?
Stroke
I've had a stroke. Do I need medicine to help prevent future strokes?
I've had some form of cardiovascular disease. How can I lower my LDL cholesterol?
What can I do to minimize my risk of having another stroke?
Asthma
I have asthma. Do I need medicine to help control it?
Are there lifestyle changes I can make to reduce my symptoms and improve my conditions?
Pneumonia
I've had pneumonia. Do I need an oxygen test?
Is there any lifestyle change I should consider to reduce or prevent future episodes of pneumonia?
Shots
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
Prescriptions I currently take:
Herbal medicines I currently take:
Traditional medicines I currently take:
Over the counter medicines I currently take:
Could these cause problems with my other medicines?
Allergies to medicines
I am allergic to the following medicines:
I am allergic to the following vaccines:
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
Could this affect my health? How often should I be screened for these?
Tests or shots in other facilities
Since my last visit, I received the following treatments at another health care facility:
Exercise
When it comes to exercise,
I exercise about days a week.
Normally when I exercise, I exercise about minutes. Is this enough?
Alcohol and Other Substances
On average, how many days per week do you have a drink of alcohol? 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).
When I drink, I usually have about
What are the most number of drinks you have had at one time in the past month?
Is there something I can do to help me drink less?
I sometimes use drugs like marijuana, cocaine or others.
Is there someone I can talk to for help about my drug use?
Smoking
When it comes to smoking, I:
I smoke:
When it comes to chewing tobacco (snuff, dip, spit tobacco), I:
Does anyone smoke at your home?
Are you exposed to tobacco smoke at work?
Depression
During the past two weeks, have you felt down, depressed, or hopeless?
During the past two weeks, have you felt little interest or pleasure in doing things you used to like to do?
Is counseling available to help me with this? Do I need counseling?
My Health Goals
How sure are you that you can manage and control most of your health problems?
My first health goal is:
My second health goal is:
My third health goal is:
