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Use this Personal Prevention Record to keep track of the
preventive care that you have received and/or will need in the future. With the help of
your health care provider, fill in how often you need each type of preventive care. Write
in the date each time you receive preventive care. Use the remaining space to record other
information (such as results of tests and the health care provider's or clinic's name).
Type of Preventive Care Enter Dates, Results, and Other Information
Blood pressure _________ _________ _________ _________
Every _____ months/years _________ _________ _________ _________
Goal: _____/_____ _________ _________ _________ _________
Cholesterol _________ _________ _________ _________
Every _____ months/years _________ _________ _________ _________
Goal: _____ mg/dl _________ _________ _________ _________
Weight _________ _________ _________ _________
Every _____ months/years _________ _________ _________ _________
Goal: _____ lbs. _________ _________ _________ _________
Fecal occult blood test _________ _________ _________ _________
Every _____ years _________ _________ _________ _________
Sigmoidoscopy _________ _________ _________ _________
Every _____ years _________ _________ _________ _________
Tetanus (Td) shot _________ _________ _________ _________
Every 10 years _________ _________ _________ _________
Pneumococcal shot _________ _________ _________ _________
Once at age 65 _________ _________ _________ _________
Influenza shot _________ _________ _________ _________
Every year starting at age 65 _________ _________ _________ _________
Dental visits _________ _________ _________ _________
Every _____ months _________ _________ _________
Powerd by www.ahrq.gov
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