Date of Most Recent Visit: 5/5/98
Age: 32
Sex: F
Is Flow Sheet in Chart?: Y
Has It Been Updated Within Last 12 Months?: N
Smoker?: N
Tobacco Counseling?: N
Health Screening Area:
Guaiac: N/A
Breast Exam: 4/98
Mammogram: N/A
PAP/Pelvic: 4/98
Comments: Prog. Notes/Lab
Date of Most Recent Visit: 5/5/99
Age: 59
Sex: M
Is Flow Sheet in Chart?: Y
Has It Been Updated Within Last 12 Months?: Y
Smoker?: Y
Tobacco Counseling?: N
Health Screening Area:
Guaiac: 7/99
Breast Exam: N/A
Mammogram: N/A
PAP/Pelvic: N/A
Comments: Prog. Notes
Date of Most Recent Visit: 5/5/99
Age: 42
Sex: F
Is Flow Sheet in Chart?: N
Has It Been Updated Within Last 12 Months?: N
Smoker?: N
Tobacco Counseling?: Y
Health Screening Area:
Guaiac: N/A
Breast Exam: NI
Mammogram: N/A
PAP/Pelvic: NI
Comments: Mental Illness, little attention paid to prevention
Date of Most Recent Visit: ____________________________
Age: ______________________________________________
Sex: ______________________________________________
Is Flow Sheet in Chart?: ______________________________
Has It Been Updated Within Last 12 Months?: ____________
Smoker?: __________________________________________
Tobacco Counseling?: _______________________________
Health Screening Area:
Guaiac: ____________________________________________
Breast Exam: _______________________________________
Mammogram: _______________________________________
PAP/Pelvic: _________________________________________
Comments: _________________________________________
Date of Most Recent Visit: ____________________________
Age: ______________________________________________
Sex: ______________________________________________
Is Flow Sheet in Chart?: ______________________________
Has It Been Updated Within Last 12 Months?: ____________
Smoker?: __________________________________________
Tobacco Counseling?: _______________________________
Health Screening Area:
Guaiac: ____________________________________________
Breast Exam: _______________________________________
Mammogram: _______________________________________
PAP/Pelvic: _________________________________________
Comments: _________________________________________
Date of Most Recent Visit: ____________________________
Age: ______________________________________________
Sex: ______________________________________________
Is Flow Sheet in Chart?: ______________________________
Has It Been Updated Within Last 12 Months?: ____________
Smoker?: __________________________________________
Tobacco Counseling?: _______________________________
Health Screening Area:
Guaiac: ____________________________________________
Breast Exam: _______________________________________
Mammogram: _______________________________________
PAP/Pelvic: _________________________________________
Comments: _________________________________________
Date of Most Recent Visit: ____________________________
Age: ______________________________________________
Sex: ______________________________________________
Is Flow Sheet in Chart?: ______________________________
Has It Been Updated Within Last 12 Months?: ____________
Smoker?: __________________________________________
Tobacco Counseling?: _______________________________
Health Screening Area:
Guaiac: ____________________________________________
Breast Exam: _______________________________________
Mammogram: _______________________________________
PAP/Pelvic: _________________________________________
Comments: _________________________________________
Date of Most Recent Visit: ____________________________
Age: ______________________________________________
Sex: ______________________________________________
Is Flow Sheet in Chart?: ______________________________
Has It Been Updated Within Last 12 Months?: ____________
Smoker?: __________________________________________
Tobacco Counseling?: _______________________________
Health Screening Area:
Guaiac: ____________________________________________
Breast Exam: _______________________________________
Mammogram: _______________________________________
PAP/Pelvic: _________________________________________
Comments: _________________________________________
Date of Most Recent Visit: ____________________________
Age: ______________________________________________
Sex: ______________________________________________
Is Flow Sheet in Chart?: ______________________________
Has It Been Updated Within Last 12 Months?: ____________
Smoker?: __________________________________________
Tobacco Counseling?: _______________________________
Health Screening Area:
Guaiac: ____________________________________________
Breast Exam: _______________________________________
Mammogram: _______________________________________
PAP/Pelvic: _________________________________________
Comments: _________________________________________
Source: Adapted from Carney et al., 1992 and Dietrich et al., 1994.