Health Maintenance

Pre-visit Questionnaire (PDF)

Plan

All Patients

[Age] year old [gender] presents for HME

#Vaccination (≥ 22 y/o)

  • Influenza season: Administer influenza vaccine

  • Most recent TDaP ≥ 10 years ago: Administer TD booster

  • ≤ 26 y/o with no history of HPV immunization and not currently pregnant: Administer 1st dose HPV vaccine and follow up in 2 to 6 months for the 2nd, 3rd dose

  • ≥ 50 y/o with no history of HZV immunization, immunocompromised state: Administer 1st dose Shingrix (RZV) vaccine, follow up in 2 to 6 months for 2nd dose

  • ≥ 65 y/o: Administer 1 dose Pneumococcal polysaccharide vaccine (PPSV23)

  • Born after 1980 with no varicella immunity and not currently pregnant: Administer 1st dose varicella vaccine, follow up in 4 to 8 weeks for 2nd dose

  • Born after 1957 and not currently pregnant: Ensure patient has received at least one MMR vaccine

  • Chronic disease or other risk factors (any age)

    • PPSV23 and HepB

      • Diabetes mellitus

      • Chronic liver disease: Add HepA

      • ESRD on hemodialysis: Add PCV13

      • HIV: Add PCV13, MenACWY

    • Asplenia: PCV13, PPSV23, MenACWY, Hib

#Depression screen: Perform PHQ-2

  • PHQ-2 score ≥ 3: Perform PHQ-9

  • PHQ-9 score ≥ 10 (moderate/severe): Discuss starting SSRI

#Alcohol use: Counsel about appropriate intake limits for age and sex

#Tobacco use: Perform tobacco cessation counseling lasting ≥ 3 minutes

  • Smoking cessation pharmacotherapy (select one)

    • Start nicotine patch

    • No history of mental illness, suicidal ideation: Start varenicline 1 week before quit date (0.5 mg qd days 1-11, 1 mg qd days 12-42). Follow-up in 12 weeks to review continuation for an additional 12 weeks.

    • Start bupropion SR 150 mg qd days 1-3 then increase to 150 mg BID

  • 55-80 y/o with ≥ 30 pk/yr history, smoked within past 15 years, and candidate for lung surgery: Refer for yearly low-dose CT

  • 65-75 y/o male with who has ever smoked: Refer for one-time AAA U/S screening

#STI/ID

  • Age 15-65 years: Screen for HIV

  • Engaged in high-risk sexual behaviors: Screen for hepatitis B, syphilis and offer preexposure prophylaxis (PrEP) therapy

  • At increased risk for TB: Place PPD and follow up for read in 48-72 hours

#Obesity (BMI > 30 kg/m2): Perform brief counseling about diet and exercise. Refer for further behavioral/dietary counseling.

#HTN: Repeat BP in office >140/>90. Trial of lifestyle modification and follow-up in 1-3 months. If BP still elevated, start antihypertensive therapy (select one):

  • Amlodipine 5 mg qd

  • Chlorthalidone 25 mg qd and obtain BMP in 2 weeks

  • History of HF, left ventricular hypertrophy, MI, DM, ADPKD and no history of CKD: Start lisinopril-HCTZ 10-12.5mg qd and obtain BMP in 2 weeks

#Skin cancer prevention in fair-skin patient ≤ 24 y/o: Counsel about UV radiation and sunscreen use

Age ≥ 40 years

#DM screening (40-70 y/o with BMI > 30 kg/m2): Obtain HbA1c

#Lipid screening (40-75 y/o): Obtain lipid panel and repeat every 3 years if not already taking a high-intensity statin

#Statin therapy: 40-75 y/o with CVD risk factor (MI/stent/angina, CVA, DM, PAD, HTN, smoking) and/or ASCVD risk > 10%. Start statin therapy.

Age ≥ 50 years

#Aspirin therapy: 50-59 y/o with life expectancy > 10 years, willing to take aspirin for > 10 years, and ASCVD > 10%. No history of GI bleed, coagulopathy, or other bleeding risk. Start aspirin 81mg qd for prevention of CV disease, colon cancer.

#Colon cancer screen (50-75 y/o): Colorectal CA screening with FIT every 1 year or colonoscopy every 10 years.

#Hepatitis C Screen: Born between 1945-1965 with no previous h/o Hep C screening. Obtain one time hepatitis C screen.

#Age > 65 years and at increased risk for falls: Recommend exercise interventions for fall prevention.

Women’s Health

#Age 18-65 years

  • ≤ 24 y/o and sexually active: Screen for chlamydia/gonorrhea infection

  • Capable of pregnancy: Start 0.4 mg folic acid daily

  • Domestic violence screen: Patient feels safe at home

#Cervical cancer screen

  • 21-29 y/o: Perform Pap q3 years

  • 30-65 y/o: Perform Pap with co-testing q5 years

#Breast cancer screen

  • Age ≥ 35 years with family h/o breast, ovarian, tubal, or peritoneal cancer: Administer screening tool, e.g. Pedigree Assessment Tool to assess need for genetic counseling, BRCA screening

  • Age >50 years: Mammogram every 2 years

  • No prior breast CA diagnosis and at increased risk: Administer screening tool to assess benefit/risk of tamoxifen/raloxifene therapy. If screening positive and patient willing to undergo treatment, consider tamoxifen 20mg vs. raloxifene 60 mg x 5 years

#Osteoporosis Screen: Age ≥ 65 years and/or positive osteoporosis risk assessment tool. Obtain DEXA scan.

Notes

  • Screening per USPSTF A and B recommendations

  • Vaccines

    • Second doses of HZV (Shingrix) and VZV may be administered 2 months following the first dose

    • Adults born before 1957 are consider MMR immune with the exception of health care workers

    • Vaccines are often referred to by trade names

  • Definition of ever smoke is 100 cigarettes in a lifetime (see AAA screening for males age 65-75 years)

  • Examples of high risk sexual behaviors include

    • Multiple sexual partners

    • Any sexual activity (oral, genital, anal)

      • Before the age of 18

      • With a non-monogamous partner and without the use of a condom or barrier protection

      • With a high risk partner, i.e. someone with a history of sex work and/or IV drug use

  • There are no clear guidelines concerning repeat lipid screening. Repeating every 3 years is a conservative recommendation per expert opinion.