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How to Use the Personal Health Guide

Read the important information that begins each section. If you don't understand something, be sure to ask your health

care provider about it.

Wherever the guide suggests you talk to your health care

provider, be sure you do. This will help you get the answers you

need to take care of your health. After talking with your health

care provider, fill in the blanks provided on certain records. This

will help you to know which services you need and how often

you need them. Bring it with you every time you see a health

care provider.

The records in the Guide can make it easier to keep

accurate information about your health and will especially helpyou with details when you get treatments in the future.

Personal Health Guide

Blood PressureMaintaining a good blood pressure will help

protect you from heart disease, stroke and

kidney problems. Ask your provider how of-

ten you need your blood pressure checked

and what a healthy blood pressure for you is. I need my blood pressure checked every

 __________ months/years. 

My blood pressure should be below

 __________/__________. 

ImmunizationsAdults need immunizations (shots) to pre-

vent serious diseases. The following are com-

mon shots that most people need:

Tetanus-diphtheria shot -- Everyone

needs this every 10 years. 

Ask your doctor about the Rubella

(German measles) shot, Pneumococcal

(pneumonia) shot, Influenza (flu) shots, and

Hepatitis B shot. 

CholesterolHaving your cholesterol checked is impor-

tant, especially if you are a man age 35-65 or

a woman age 45-65. Ask your provider what

a healthy cholesterol level is for you and how

often you need it checked.My cholesterol should be less than

 __________ mg/dL. 

My cholesterol should be checked every

 __________ year(s). 

WeightWeighing too much or too little can lead to

health problems. Talk with your providerabout what a healthy weight for you is and

ways you can control your weight.

I weigh __________ pounds. 

A healthy weight for me is between

 __________ and __________ pounds. 

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Colorectal CancerColorectal cancer is the third leading cause

of deaths from cancer. If it is caught early, it

can be treated. If you are 50 years of age or

older, you should have colorectal tests

regularly to detect it. The tests you may have

are:Fecal Occult Blood Test -- to look for small

amounts of blood in your stool. This test

should be done yearly. 

Colonoscopy -- to look inside the rectum and

colon using a small, lighted tube. Your health

care provider will do this in the office or

clinic. This test should be done every 10

years. 

Tell your health care provider if you have

had polyps or if you have a family member(s)with cancer of the intestine, breast, ovaries,

or uterus, you may need testing before age

50 or more often.

Ask your health care provider at what age

you need to start and how often you need

these tests:

I need fecal occult blood tests every

 ________ year(s) starting at age ________ . 

I need colonoscopy every __________ yearsstarting at age __________ . 

Oral Health CareGood oral health care is important for your

teeth and general health. Visit your dentist

regularly for checkups.

I need to visit my dentist every __________

month(s).

Additional Preventive CareTalk with your doctor about any of the

following additional preventive care services:

Nutrition, Depression, Tobacco Use,

Physical Activity, Alcohol and other drug use

Preventive Care For Women

Mammogram

Women ages 40 and older should begin get-

ting mammograms every year and continue

to do so as they long as they are in good

health. Make sure to tell your provider if 

your mother or a sister has had breast can-cer. You may need to have mammograms

more often than other women.

My mother or sister has had breast cancer

(yes/no). 

I need a mammogram every __________

year(s), starting at age __________ . 

Pap SmearWomen need to have Pap smears every year

starting at age 20. Another option is to have

the liquid Pap test every other year (if a

woman has 3 mornal tests in a row, test

every 2-3 years unless you are at high risk. At

age 70 and older, those who also have had

no abnormal Pap tests in the last 10 years

may choose to stop).

Tell your health care provider if you have

had genital warts, sexually transmitted dis-

eases (STDs/VD), multiple sexual partners or

abnormal Pap smears. You may need Pap

smears more often than other women.

I need a Pap smear every _________ year(s). 

Preventive Care For MenTalk with your doctor about the potential

benefits and limitations of prostate cancer

testing. Beginning at age 50, men should be

offered the prostate-specific antigen (PSA)

test and the digital rectal exam (DRE) every

year.

I need a prostate exam every ______ year(s).

For more information about how to stay healthy, call 

the American Cancer Society at 1-800-227-2345,

www.cancer.org or your local health department. 

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Key Records

Personal Information

Staying on top of your health history can be challenging. The records in this Guide can help

you keep track of information. First, record your background information here. You can access

other records for preventive tests and exams (shots), women's health exams, additional pre-ventive care measures, and medications.

Medication Record 

Name:

Address:

Telephone:

In an emergency, contact:

Allergies:

Heathcare Provider Name and

Phone Number:

Medical Insurance Name and

Phone Number:

Medication Name: Dose: How Often:

Notes:

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Personal Prevention RecordUse 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). Use the records for Preventive Care For

Women, Additional Preventive Care, and Medication to keep track of other important medical

information.

Type of Care: How Often: Dates of 

Tests:

Results: Goal:

Blood Pressure Every ____ months/

years

Cholesterol Every ____ months/

years

 _____ mg/dl _____

Weight Every ____ months/

years

 ____________ lbs

Fecal Occult

Blood Test (FOBT)

Every ____ years

Colonoscopy 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

Other Prevention

Care:

Every ____ months/

years

Every ____ months/

years

Every ____ months/

years

For Women Only:

Mammogram Every ____ years

Pap Smear Every ____ years

For Men Only:

Testicular Exam Every ____ years

Prostate Exam Every ____ years