Preventive Care Checklist Form© Name:

Sex:
For average-risk, routine, male DOB: Age:
health assessments
Developed by: Dr. V. Dubey, Dr. R. Mathew, Dr. K. Iglar Health Card: Tel:
Revised by: Dr. A. Ischayek, Dr. J. Ridley
Please note: Address:
Bold = Grade A, or strong evidence (from the Canadian Task Force on Preventive Health Care)
Italics = Grade B, or weak evidence (from the Canadian Task Force on Preventive Health Care)
Plain text = Guidelines (from other Canadian sources)
(See reverse for references, insert for explanations) Date:
Current Concerns Lifestyle/Habits
Diet: Smoking:
Fat/Cholesterol
Fiber Alcohol:
Calcium
Drugs:
Sodium
Exercise: Sexual History:
Work/Education:
Family Planning/
Poverty: Contraception:
Family: Sleep:
Relationships:

Update Cumulative Patient Profile

c Family History c Medications
c Hospitalizations/Surgeries c Allergies

Functional Inquiry
Normal Remarks Normal Remarks

HEENT: c MSK: c

CVS: c Neuro: c

Resp: c Derm: c

GI: c Mental
Health: c
GU: c
Constitu-
Sexual tional SX: c
Function: c

Behavioural Alcohol c Yes c No Personal Safety

c adverse nutritional habits c case finding for problem c hearing protection
c dietary advice on fat/cholesterol (30-69 yrs) drinking c noise control programs
Counselling
Education/

c adequate calcium intake (1000 to 1500mg/d) c counselling for problem drinking c seat belts
c adequate vitamin D (400 to 1000 IU /d)
c regular, moderate physical activity
c avoid sun exposure, use protective clothing Elderly c Yes c No Parents with
c safe sex practices/STI counselling c cognitive assessment children c Yes c No
(if concerns) c poison control
Overweight (BMI 25-29) or c fall assessment (if history of falls) prevention
Obese (BMI 30-39) c Yes c No
c smoke detectors
c structured behavioural interventions for weight loss
unless otherwise stated
For general population

c non-flammable
c screen for mental illness if obese Oral Hygiene sleepwear
c multidisciplinary approach c brushing/flossing teeth c hot water thermostat
Smoking c Yes c No c fluoride (toothpaste/ settings (<54°C)
supplement)
c smoking cessation
c tooth scaling and prophylaxis
c nicotine replacement therapy/other drugs
c smoking cessation
c dietary advice on fruits and green leafy vegetables
c referral to validated smoking cessation program
Disclaimer: This form is a guide to the adult periodic Endorsed by:
health examination. Last updated February 2015.
The recommendations are for average-risk adults.

PH1501GB319 Male
 Please note:
Bold = Grade A, or strong evidence (from the Canadian Task Force on Preventive Health Care)
Italics = Grade B, or weak evidence (from the Canadian Task Force on Preventive Health Care)
Name: Plain text = Guidelines (from other Canadian sources)

Physical Examination
BP: HT: WT: BMI:

Age ≤ 64 years ≥ 65 years

c Hemoccult multiphase q1-2 yrs (≥50 yrs) c Hemoccult Multiphase q1-2 yrs (up to 74 yrs)
OR c Sigmoidoscopy OR c Sigmoidoscopy
Labs/Investigations

OR c Colonoscopy
c Gonorrhea/Chlamydia/Syphilis/HIV/HBV/HCV screen (high risk)
c Fasting Lipid Profile q1-5 yrs (≥40 yrs or sooner if at risk)
c A1C or FPG if at risk
c Bone Mineral Density if at risk
OR c Colonoscopy
c Gonorrhea/Chlamydia/Syphilis/HIV/HBV/HCV screen (high risk)
c Audioscope (or inquire/whispered voice test)
c Fasting Lipid Profile q1-5 yrs (≤75 yrs)
c A1C or FPG if at risk
c Bone Mineral Density

c Tetanus vaccine q10 yrs c Meningococcal vaccine c Tetanus vaccine q10 yrs
c Influenza vaccine q1 yr c Herpes zoster vaccine (≥60 yrs) c Influenza vaccine q1 yr c Herpes zoster vaccine
Immunizations

c Acellular pertussis vaccine c Pneumococcal vaccine

c Varicella vaccine (2 doses) c Acellular pertussis vaccine
c Human papillomavirus vaccine (≤26 yrs of age or msm) c Varicella vaccine (2 doses)
c Measles/Mumps/Rubella vaccine

Assessment and Plans

Date: Signature:
References: See explanation sheet for references and recommendations.

Disclaimer: This form is a guide to the adult periodic Endorsed by:

health examination. Last updated February 2015.
The recommendations are for average-risk adults.

PH1501GB319 Male