LIFESTYLE

 

• Physical Activity

  • In mins/week 

    • Recommend 150 minutes of aerobic activity weekly if no cardiac or other contraindications

• Nutrition / Diet 

  • Scale of 0 (very poor) – 10 (excellent)

    • This is the patient's subjective scoring

  • Vegetarian?

• Smoking – cigarettes / other per day:

• Alcohol 

  • Drinks per week:

• Birth control method?

• Menopause?

• Sleep – hours per day:

• Stress Level 

  • Scale of 0 (very low) – 10 (very high):

    • This is the patient's subjective scoring

• Poverty screen

  • Are you able to make ends meet each month?

  • Are you taking any prescription medications?

  • Have any of these changed recently?

• Allergies?

 

PREVENTIONS

 

The list for an individual is based upon both national expert consensus and individual considerations unique to each patient

 

• Blood Test – every 3 yrs. unless abnormal

  • OHIP only pays if it was previously abnormal

  • Prior Test Date:

  • Action:

• BMD – every 5 yrs unless abnormal

  • ​Prior Test Date:

  • ​Action:

• Colonoscopy / FIT 

  • ​Colonoscopy every 10 yrs unless abnormal or family history

  • FIT every 2 years if no colonoscopy

  • ​Prior Test Date:

  • ​Action:

• Pap – every 3 yrs unless abnormal

  • Prior Test Date:

  • Action:

• Mammogram– every 2 yrs unless abnormal

  • ​Prior Test Date:

  • ​Action:

• Pneumonia Vaccine (for patients with chronic disease)

  • Pneumo 23

  • Prevnar 13

    • Not covered by OHIP

  • Prior Vaccination Date:

  • Action:

• Herpes Zoster (“Shingles”)

  • Zostavax or Shingrix x 2 in the past

  • Prior Vaccination Date:

  • Which one?

  • Action:

• Tetanus – every 10 yrs

  • Prior Vaccination/Booster Date:

  • Action:

• Flu Vaccine

  • Annual

  • Prior Vaccination Date:

  • Action:

• Covid – 19 

  • Prior Vaccination Date:

  • Action:

 

SUMMARY OF PREVENTATIVE CARE ACTION

 

The patient has been informed of recommended preventions and has agreed to the following:

 

Dr. Carson Authorization on tests, cancer screens, and vaccines to be carried out:

 

ADDITIONAL WELLNESS CHECK

 

• Vision

• Hearing

• Falls/Balance 

• Memory

• Sun Exposure / Skin Care

• Vitamin and Mineral Supplements:​

  • Vitamin D

  • Calcium/Dairy

  • Salt intake

• Caffeine

• Water

 

Patients concerns for follow up with Dr. Carson: