ࡱ > L O K Z bjbj 44 x x 8
^ ^ ] ] ] q q q 8 | q * A A A A A * * * * * * * , // P * ] v | * A A 5 * X A ] A * * & | ' 6 r( A 6EC q J L v' r* * 0 * ' / / $ r( r( / ] ( * * * / ^ g :
Preventive ServiceFrequency Last Done Body Mass Index (BMI)____
Height _______
Weight ______
AnnuallyBlood Pressure _______/_______
Every 2 yrs, if BP 120-139/80-89 mm hgVision
Every 3 yrs up to age 40;
Every 2 yrs aged 40+Abdominal Aortic AneurysmOnce, between the age range of 65-75 and smoked 100+ cigarettes in lifetimeCholesterol TestingRegularly beginning at age 20 with risk factorsDiabetes ScreeningWith a sustained BP >/= 135/80 mm HgColorectal Cancer ScreeningAnnually, Fecal Occult Blood Stool (FOBS);
Every 5 yrs, Sigmoidoscopy with FOBS;
Every 10 yrs, ColonoscopySexually Transmitted Diseases (STDs)As necessary for those with risk factorsDepression ScreeningAs necessary for those with risk factorsAlcohol Misuse ScreeningAs necessary for those with risk factorsImmunizations:
Pneumococcal (Pneumonia) Vaccine
Influenza (Flu) VaccinePneumonia: 1-2 doses up to age 64;
Pneumonia: 1 dose age 65+
Influenza: Annually
Other
Your major risk factors:
Family history of ____________________ Obesity_______ Diabetes_______ Hypertension______ Fall Risk______ Smoking Use______ Other___________
Recommendations for improvement:
Diet_____ Tobacco Cessation_____ Weight Management____ Exercise____ Other_____
Referrals
[
Patient Name______________________________ Date______________________________
atient Name
MENS PREVENTIVE WELLNESS PLAN
For Staff Use: [list handouts, referrals, or other follow-up instructions here]
" # - . / v w 6 7 R j k
b c o p r h, 5 h- 5 hE> 5h> h 5 h> 5 h 5 h|K h> h> h> 5 h|K ha1 h> h{j 5h> ha1 5ha1 ha1 5CJ aJ %j hSP( 5CJ UaJ mH nH u ; # . $$If a$gd{j $$If a$gdVI $a$gd, gda1 . / I Z k l u v I @ @ @ @ @ @ $If gd@ kd $$If l F 8 ' h
t 0 6 4 4
l a p ytDTt v w o f f f Y L C $If gd@
& F $If gd>
& F $If gd{j $If gd kd $$If l F 8 ' h
t 0 6 4 4
l a ytDTt o f f Y L f
& F $If gd{j
& F $If gdS $If gd@ kd $$If l F 8 ' h
t 0 6 4 4
l a ytDTt 7 o f ] f $If gd- $If gd@ kdX $$If l F 8 ' h
t 0 6 4 4
l a ytDTt o f f f $If gd@ kd $$If l F 8 ' h
t 0 6 4 4
l a ytDTt
o f f ] $If gd@ $If gd~/ kd $$If l F 8 ' h
t 0 6 4 4
l a ytDTt
!
L
r
o f Y Y L f
& F $If gd>
& F $If gdS $If gd@ kd_ $$If l F 8 ' h
t 0 6 4 4
l a ytDTt
o f ] T $If gd@ $If gd> $If gdS kd $$If l F 8 ' h
t 0 6 4 4
l a ytDTt
o f ] f $If gd> $If gd@ kd $$If l F 8 ' h
t 0 6 4 4
l a ytDTt 8 a b o f ] f $If gd~/ $If gd@ kdf $$If l F 8 ' h
t 0 6 4 4
l a ytDTt b c r o f f f Y L Y f
& F $If gd@
& F $If gd> $If gd@ kd $$If l F 8 ' h
t 0 6 4 4
l a ytDTt
f ] P
h$If ^hgd, $If gd> kd $$If l F 8 ' h
t 0 6 4 4
l a ytDTt $If gd@ ) *
+
5
7
8
o j j j j j j j j h h gda1 kdm $$If l F 8 ' h
t 0 6 4 4
l a ytDTt X ^ _ h q }
)
*
+
5
6
7
8
9
;
<
>
?
A
B
E
F
R
S
뾺 h)y h 5OJ QJ ^J hSP( h h)y h OJ QJ ^J hI j hI UhFE hFE 5h j hSP( UmH nH u h> hb 5h> h~/ 5 h(+ 5 h 5 h 5h> ha1 5hb ha1 5CJ aJ 38
:
;
=
>
@
A
C
D
E
F
R
S
W X Y Z gdwRE $a$gdZ gdb
: C V W X Y Z Ծ hFE hFE 5hI hFE h 6 h- 6 h 6hSP( h h OJ QJ ^J h)y h 5OJ QJ ^J h 5OJ QJ ^J 2 1h:pFE / =!8"8#*$ % $$If !v h5 55 #v #v#v :V l
t 0 6, 5 5 5hp ytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt $$If !v h5 55 #v #v#v :V l
t 0 65 5 5hytDTt ^ 2 0 @ P ` p 2 ( 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 8 X V ~ _HmH nH sH tH @ ` @ a1 N o r m a l CJ _HaJ mH sH tH D A` D
D e f a u l t P a r a g r a p h F o n t R i@ R 0 T a b l e N o r m a l 4
l 4 a ( k (
0 N o L i s t j j a1
T a b l e G r i d 7 :V 0 4 4 b H e a d e r
H$ 6 6 b H e a d e r C h a r CJ aJ 4 "4 b F o o t e r
H$ 6 16 b F o o t e r C h a r CJ aJ H BH {j B a l l o o n T e x t CJ OJ QJ ^J aJ N QN {j B a l l o o n T e x t C h a r CJ OJ QJ ^J aJ PK ! [Content_Types].xmlj0Eжr(Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi} ;~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭? PK ! ֧ 6 _rels/.relsj0 }Q%v/C/} (h"O
= C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_ 6LR7`0̞O,En7Lib/Se е PK ! ky theme/theme/themeManager.xml M
@}w7c(Ebˮ CAǠҟ7՛K
Y,
e.|,H ,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+&
8 PK ! P theme/theme/theme1.xmlYOo6w toc'vuر-Mn iP@I}úama[إ4:l ЯGRX^6؊>$ !)O^rC$y@ /yH*)UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSe bORD۫qu gZo~ٺlAplxpT0+[}`j zA V2Fi@qv֬5\|ʜ̭NleXd sjcs7f
W+Ն7` g ȘJj|h(KD-
dXiJ؇(x$( :;˹! I_TS 1?E ??ZBΪmU/ ?~xY'y5g&/ɋ>GMGeD3Vq%'#q$8K )fw 9:ĵ
x}rxwr:\TZaG*y8IjbRc|XŻǿI
u3KGnD 1NIBs
RuK>V.E L+M2#'fi ~V vl{u8z H
* :( W ☕
~JTe\O*tHGHY }KNP*ݾ˦ TѼ9/#A7qZ $*c?qUnwN%Oi4 =3ڗP
1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g-
eW
)6-rC Sj
id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q% p%m&]caS l=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f
Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ .uχYC6OMf3or$5N HT[XF64T,ќM0E)`#5XY`פ ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R 3U~7+#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vp IYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07% < ҍ PK !
ѐ ' theme/theme/_rels/themeManager.xml.relsM
0wooӺ&݈Э5
6?$Q
,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{ P8g/ ]QAsم(#L[ PK- ! [Content_Types].xmlPK- ! ֧ 6 + _rels/.relsPK- ! ky theme/theme/themeManager.xmlPK- ! P theme/theme/theme1.xmlPK- !
ѐ ' theme/theme/_rels/themeManager.xml.relsPK ]
Z Z 4
Z . v
b 8
Z
L # A A @ v (
H
#
N
3
H
#
H
#
B
S ? 5 Z y' t < & t a / < t ( t Y f 8 : ; = > @ A C E [ 8 : ; = > @ A C E [ 3 PZF j` d`&x&P] +Bhb X;ID 2XBw l}_/ h^h`OJ QJ o( 8^8`OJ QJ ^J o( o ^`OJ QJ o( ^ `OJ QJ o( ^ `OJ QJ ^J o( o x^x`OJ QJ o( H^H`OJ QJ o( ^`OJ QJ ^J o( o ^`OJ QJ o( h^h`OJ QJ o( 8^8`OJ QJ ^J o( o ^`OJ QJ o( ^ `OJ QJ o( ^ `OJ QJ ^J o( o x^x`OJ QJ o( H^H`OJ QJ o( ^`OJ QJ ^J o( o ^`OJ QJ o( h^h`OJ QJ o( 8^8`OJ QJ ^J o( o ^`OJ QJ o( ^ `OJ QJ o( ^ `OJ QJ ^J o( o x^x`OJ QJ o( H^H`OJ QJ o( ^`OJ QJ ^J o( o ^`OJ QJ o( h^h`OJ QJ o( 8^8`OJ QJ ^J o( o ^`OJ QJ o( ^ `OJ QJ o( ^ `OJ QJ ^J o( o x^x`OJ QJ o( H^H`OJ QJ o( ^`OJ QJ ^J o( o ^`OJ QJ o( h^h`OJ QJ o( 8^8`OJ QJ ^J o( o ^`OJ QJ o( ^ `OJ QJ o( ^ `OJ QJ ^J o( o x^x`OJ QJ o( H^H`OJ QJ o( ^`OJ QJ ^J o( o ^`OJ QJ o( h^h`OJ QJ o( 8^8`OJ QJ ^J o( o ^`OJ QJ o( ^ `OJ QJ o( ^ `OJ QJ ^J o( o x^x`OJ QJ o( H^H`OJ QJ o( ^`OJ QJ ^J o( o ^`OJ QJ o( l} X;I d`& PZF + 2X u ? I # $U > M G
!y 4 \- D> %+ je U$ SP( (+ &b- q/ !3 s43 O 8 4X< G ? wRE 0WE VI K AL oM AN G(Q FqR S Oa avb 4*k ? m Bq DTt v x y )y Ly My hz | +} x2~ g . H\ !# ]@ E> u x m_ J |K N :t +g ) i U Z r D & !
7 , C T @ 5 = hI n Hn ]r i S * &F } ~/ A H {j L o/ U - a1 FE I fr b 6; h- I 8 : @ Z @ U n k n o w n G * T i m e s N e w R o m a n 5 S y m b o l 3. * A r i a l 5. * a T a h o m a ?= * C o u r i e r N e w ; W i n g d i n g s A B C a m b r i a M a t h " q h
3g
3g F q q ! 8* 20 6 6 3 HX ? a1 2 ! x x
J o h n s H o p k i n s C h r i s B $ Oh +'0
8 D P
\ h p x Johns Hopkins Normal.dotm ChrisB 2 Microsoft Office Word @ d @ < <@ N>C@ N>C q ՜. +,0 h p
Johns Hopkins 6 Title
! " $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : < = > ? @ A B D E F G H I J M N Q R o o t E n t r y F ECP D a t a
1 T a b l e # / W o r d D o c u m e n t
44 S u m m a r y I n f o r m a t i o n ( ; D o c u m e n t S u m m a r y I n f o r m a t i o n 8 C M s o D a t a S t o r e 0fEC6EC O Z D U I 4 L C L = = 2 0fEC6EC I t e m
P r o p e r t i e s U C o m p O b j
y
F' Microsoft Office Word 97-2003 Document
MSWordDoc Word.Document.8 9q