Adult Health Maintenance Form

An Adult Health Maintenance exam is a medical appointment that provides preventive services, counselling, education and disease screening, based on age and gender. For that, this particular form must be filled which is not restricted to use within any particular state but is a general form.

How to fill the Adult Health Maintenance Form?

  • STEP 1: Begin the form by entering personal details of the adult in question – full name, date of birth and medical record number.
  • STEP 2: The first table to be filled is the problems evaluated and test results. List down these details, along with their respective consultants and specialists. If a previous adult health maintenance sheet has to be referred to, tick the box.
  • STEP 3: Now comes to the main part of the health maintenance. Enter the following health details in case of women – breast exam, mammogram, breast self- exam education and PAP test; and for men, enter the following – testicular self-exam education, DRE (digital rectal exam) and PSA test details.
  • STEP 4: For elderly people, enter the following details – mini-mental status exam, functional assessment and advance directives.
  • STEP 5: General details for all adults that need to be entered are as following – flex sig/colon, stool for occult blood, dental exam, dilated eye exam, diabetic foot exam, monofilament exam, ECG and a high-risk screening tool.

When all these tables are filled in, the Adult Health Maintenance Form is completed.

Adult Health Maintenance

Preview Adult Health Maintenance Form