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Personal Health Guide

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 help
you with details when you get treatments in the future.

Blood Pressure Cholesterol

Maintaining a good blood pressure will help Having your cholesterol checked is impor-
protect you from heart disease, stroke and tant, especially if you are a man age 35-65 or
kidney problems. Ask your provider how of- a woman age 45-65. Ask your provider what
ten you need your blood pressure checked a healthy cholesterol level is for you and how
and what a healthy blood pressure for you is. often you need it checked.
I need my blood pressure checked every My cholesterol should be less than
__________ months/years. __________ mg/dL.
My blood pressure should be below My cholesterol should be checked every
__________/__________. __________ year(s).

Immunizations Weight
Adults need immunizations (shots) to pre- Weighing too much or too little can lead to
vent serious diseases. The following are com- health problems. Talk with your provider
mon shots that most people need: about what a healthy weight for you is and
Tetanus-diphtheria shot -- Everyone ways you can control your weight.
needs this every 10 years. I weigh __________ pounds.
Ask your doctor about the Rubella A healthy weight for me is between
(German measles) shot, Pneumococcal __________ and __________ pounds.
(pneumonia) shot, Influenza (flu) shots, and
Hepatitis B shot.
Colorectal Cancer Preventive Care For Women
Colorectal cancer is the third leading cause Mammogram
of deaths from cancer. If it is caught early, it Women ages 40 and older should begin get-
can be treated. If you are 50 years of age or ting mammograms every year and continue
older, you should have colorectal tests to do so as they long as they are in good
regularly to detect it. The tests you may have health. Make sure to tell your provider if
are: your mother or a sister has had breast can-
Fecal Occult Blood Test -- to look for small cer. You may need to have mammograms
amounts of blood in your stool. This test more often than other women.
should be done yearly.
My mother or sister has had breast cancer
Colonoscopy -- to look inside the rectum and (yes/no).
colon using a small, lighted tube. Your health
I need a mammogram every __________
care provider will do this in the office or
year(s), starting at age __________ .
clinic. This test should be done every 10
Tell your health care provider if you have
had polyps or if you have a family member(s)
Pap Smear
with cancer of the intestine, breast, ovaries, Women need to have Pap smears every year
or uterus, you may need testing before age starting at age 20. Another option is to have
50 or more often. the liquid Pap test every other year (if a
woman has 3 mornal tests in a row, test
Ask your health care provider at what age every 2-3 years unless you are at high risk. At
you need to start and how often you need age 70 and older, those who also have had
these tests: no abnormal Pap tests in the last 10 years
I need fecal occult blood tests every may choose to stop).
________ year(s) starting at age ________ . Tell your health care provider if you have
I need colonoscopy every __________ years had genital warts, sexually transmitted dis-
starting at age __________ . eases (STDs/VD), multiple sexual partners or
abnormal Pap smears. You may need Pap
smears more often than other women.
Oral Health Care I need a Pap smear every _________ year(s).
Good oral health care is important for your
teeth and general health. Visit your dentist
regularly for checkups.
I need to visit my dentist every __________
Preventive Care For Men
month(s). Talk 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)
Additional Preventive Care test and the digital rectal exam (DRE) every
Talk with your doctor about any of the year.
following additional preventive care services: I need a prostate exam every ______ year(s).
Nutrition, Depression, Tobacco Use,
Physical Activity, Alcohol and other drug use
For more information about how to stay healthy, call
the American Cancer Society at 1-800-227-2345, or your local health department.
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.




In an emergency, contact:


Heathcare Provider Name and

Phone Number:

Medical Insurance Name and

Phone Number:

Medication Record

Medication Name: Dose: How Often:

Personal Prevention Record
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). Use the records for Preventive Care For
Women, Additional Preventive Care, and Medication to keep track of other important medical

Type of Care: How Often: Dates of Results: Goal:

Blood Pressure Every ____ months/
Cholesterol Every ____ months/ _____ mg/dl _____
Weight Every ____ months/ ____________ lbs
Fecal Occult Every ____ years
Blood Test (FOBT)
Colonoscopy Every ____ years

Tetanus (Td) Shot Every 10 years

Pneumococcal Once at age 65

Influenza Shot Every year starting at
age 65
Dental Visits Every ____ months

Other Prevention
Every ____ months/
Every ____ months/
Every ____ months/
For Women Only:

Mammogram Every ____ years

Pap Smear Every ____ years

For Men Only:

Testicular Exam Every ____ years

Prostate Exam Every ____ years